The Texas Health & Human Services Commission’s (HHSC) final rules regarding physician billing for services provided by an APRN or PA became effective Jan. 1, 2015, and include limitations on such billing arrangements. See 39 Tex. Reg. 9884 (Dec. 19, 2014). The adopted rule requires that a physician billing for services provided by an APRN or PA under the physician’s Medicaid billing number must make a decision regarding the patient’s care or treatment on the same date of service as the billable medical visit and documented that decision in the patient’s record. See Tex. Admin. Code Tit. 1 §354.1062. If a physician billing for such services does not make a decision regarding the patient’s care or treatment on the same date of service, the physician must note on the claim that the services were provided by a supervisee. See Tex. Admin. Code Tit. 1 §354.1001.

Although the adopted rule is less restrictive than the proposed language described in our earlier post, the regulation imposes standards significantly different than Medicare for billing services under a physician’s billing number when those services are performed by an APRN or PA. Accordingly, practices that utilize “incident-to” billing for Medicare or other patients should ensure that appropriate processes are in place to document and bill for services in compliance with the new Medicaid requirements.

It is notable that the new HHSC regulations require documentation to reflect the requisite physician decision-making; even if the physician decision-making actually occurred, payment may be denied or recouped, and liability may arise under false claims prohibitions, if the decision-making is not documented for claims billed under a physician billing number.