The Texas Health & Human Services Commission (HHSC) proposed changes on Oct. 17, 2014, to its regulations that largely prohibit “incident to” billing for advanced practice registered nurse (APRN) and physician assistant (PA) providers. Specifically, changes proposed to Tex. Admin. Code Title 1 §§355.1001 and 355.1062 prohibit a service performed by an APRN or PA from being billed under the billing number of a supervising physician unless the physician made a decision regarding the patient’s care or treatment during the billable medical visit and documented that decision in the patient’s record. See 39 Texas Register 8107 (Oct. 17, 2014).

While Texas Medicaid regulations currently do not specifically authorize “incident to” billing (billing for a service performed by an APRN, PA or other person as if it was performed by the physician), Medicaid regulations arguably appear to acknowledge “incident to” billing. For example, the Texas Medicaid Provider Procedure Manual states that an APRN or PA employed or remunerated by certain entities, including a physician, may not bill independently for services if doing so would result in duplicate payment for the services (i.e., both the physician and APRN or PA bill for the service). See Texas Medicaid Provider Procedures Manual, Vol 2. Medical and Nursing Specialists, Physicians, And Physician Assistants Handbook §8.2 (Oct. 2014).

The proposed change is a significant departure from Medicare “incident to” billing principles and will require practices seeing both Medicare and Medicaid patients to carefully monitor billing. Under the proposed rule, APRN or PA service may only be billed as if the physician performed the service if the physician made a decision regarding the patient’s care or treatment during the billable medical visit and documented that decision in the patient’s record. See 39 Texas Register 8109 (Oct. 17, 2014). If a physician bills for an APRN or PA service and the physician does not meet the requirement above, the physician must indicate on the claim that service was performed by an APRN or PA. Currently, HHSC directs use of the modifier SA to reflect APRN services and U7 to reflect PA services. See Texas Medicaid Provider Procedures Manual, Vol 1. §6.3.5 (Oct. 2014).

Although the requirement for a physician to render a medical decision during a patient’s medical visit represents a significant limitation, the lack of specificity regarding the manner in which physician supervision is to be provided creates potential for certain practice arrangements utilize APRNs and PAs with more certainty regarding compliance when those services are billed under a physician’s billing number.

Written comments on the proposal may be submitted by Nov. 16, 2014, to Alexander Melis, project manager, 4900 N. Lamar Blvd., Mail Code H310, Austin, TX 78751; by fax to 512-730-7472; or by email to alex.melis@hhsc.state.tx.us.