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24.1.4 Personal Supervision Versus Direct Supervision
Physician services include reasonable and medically necessary services that are ordered and performed by a physician or under the personal supervision of a physician and that are within the scope of practice of his or her profession, as defined by state law. The physician must examine the client, make a diagnosis, establish a plan of care, and document these tasks on the appropriate client medical records before submitting claims. If such documentation is not present in the client's medical record, then any payment may be recouped. Services are benefits if provided in the office, the client's home, the hospital, or elsewhere.
To be payable by the CSHCN Services Program, the services must be personally performed by the physician or by a qualified person working under the personal supervision of the physician. Personal supervision means that the physician must be in the building of the office or facility when and where the service is provided. Direct supervision means the physician must be physically present in the room at the time the service is provided. In instances where one physician is taking calls for another physician, the performing physician must bill the services provided.
TMHP may make payments to a physician for CSHCN Services Program-covered services that are provided by another physician who is acting as his or her substitute. Such a substitution arrangement may be either an informal reciprocal arrangement of 14 days or fewer, or a long-term arrangement (up to 90 days) involving per diem or fee-for-time compensation.
The substituting physician is not required to enroll with the CSHCN Services Program. The name and address of the substituting physician are not required documentation on the claim.
If a provider bills for a substitute physician, the modifier Q5 or Q6 must follow the procedure code in Block 24D of the CSM-1500 claim form to indicate that the services were provided by a substituting physician.
If an attending physician provides personal and identifiable direction to interns or residents who are participating in the care of a CSHCN Services Program client in a teaching setting through an approved and accredited training program by the appropriate accreditation agencies, the physician's services are a benefit. For major surgical procedures and other complex and dangerous procedures or situations, the attending physician must be physically present during the procedure or situation to provide personal and identifiable direction. If personal and identifiable direction is not provided or is not appropriately documented, any payment for services may be recouped.
To demonstrate that personal and identifiable direction was provided, the attending physician must have:
• Reviewed the client's history and physical examination and personally examined the client within a reasonable period after the client's admission and before the client's discharge.
•Confirmed or revised the client's diagnosis.
•Determined the course of treatment to be followed.
•Ensured that any supervision required by the interns or residents was provided.
•Entered the appropriate daily documentation of the tasks identified above in the client's medical record before the claim is submitted.
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