TMPPM 2008 > Texas Medicaid Services > Physician > Benefits and Limitations

36.3.6 Physician Services in a Long Term Care (LTC) Nursing Facility

The Department of Aging and Disability Services (DADS) requires initial certification and recertification of Medicaid clients in nursing facilities by physicians in accordance with guidelines set forth in federal regulations. Physician visits for certification and recertification are considered medically necessary, and are reimbursable by Medicaid whether performed in the physician's office or the nursing facility.

The Omnibus Budget Reconciliation Act (OBRA) of 1987 included legislation on Preadmission Screening and Resident Review (PASARR). PASARR requires that all admissions to a Medicaid-certified distinct part of a nursing facility be screened for mental illness, mental retardation, or a related condition. This screening prevents inappropriate placement of clients in Medicaid-certified nursing facility beds.

DADS uses the Client Assessment Review and Evaluation (CARE) Form 3652-A to satisfy PASARR screening requirements. All individuals must have a preadmission screening completed before admission to the nursing facility. The screening is performed by the hospital or the nursing facility completing a CARE Form 3652-A with a purpose code P. Individuals whose CARE Forms have a Y checked in Item 34 must have a Level II screening conducted by DADS.

Physicians and hospitals may obtain written instructions on the completion and processing of the CARE form by visiting the following website at www.dads.state.tx.us/handbooks/instr/3000/F3652-A.

If the attending physician delegates health-care tasks to a qualified PA in an intermediate care/SNF, the physician services are covered if the supervision or delegation is consistent with the Texas Medical Board's rules and regulations. Services provided by PAs in intermediate care/SNFs must be consistent with the requirements of DADS agency rules [§§16.1906, 16.1912, 16.3017(c), and 16.3207(a)] as they relate to operating policies and procedures, client-patient care policies, conformance with physician orders, and drug orders. If the supervision of the delegated task is not appropriately documented in the patient's chart, any payment for services may be recouped.

Rehabilitation services (for example, physical therapy [PT], occupational therapy [OT], and speech-language pathology [SLP]) must be made available to nursing facility residents on an as-needed basis as ordered by the attending physician, and must be provided by the nursing facility staff or furnished by the facility through arrangements with outside qualified resources. Clients who need these services cannot be admitted to the nursing facility if the facility is unable to provide these services as needed. Payment for these services is included in the reimbursement made to the nursing facility; they may not be billed to TMHP. If these services cannot be furnished by the extended care facility, it is the facility's responsibility to provide transportation for the client to a provider to render these services. The Texas Medicaid Program must not be billed for the rehabilitation services or the transportation charges in these situations.

Physician visits to Medicaid patients confined in an extended care facility are not limited when they are seen for a diagnosis of illness or injury. The CMS-1500 claim form must document the medical necessity of the visit by listing the specific diagnosis in Block 21 or the appropriate electronic field.

Refer to: "Nursing Facility Services" for additional information.