Medical Billing Guidelines for Texas

The increasing cost of medical care places particular emphasis on correct medical billing. The medical billing guidelines that are in place ensure that patients are not being overcharged. In Texas, medical billing is regulated according to the type of coverage. Texas recognizes three types of coverage: Medicare, Medicaid and commercial plans.

Medicaid

• To ensure prompt payment from Medicaid, the provider should always include their Medicaid provider identification number on the bill. Medicaid's billable services are limited to those that are reasonably and medically necessary as deemed by the Health and Human Services Commission or its designee. Services must be performed under a licensed physician, either a medical doctor or a doctor of osteopathy. Services given by an advance practice nurse or a physician assistant are covered if the services provided are within the scope of their respective practices as defined by Texas law. The services must also be consistent with the rules and regulations given by the appropriate state licensing authority. Advance practice nurses that are employed by Medicaid providers may not bill for their services if doing so would result in duplicate payments for the same services.

  Nurse practitioners, clinical nurse specialists and physician assistants are reimbursed at 92 percent of the rate paid to physicians. They are reimbursed at 100 percent of the physician rate for X-ray services, injections and lab work. Physician assistant services that are billed under a physician or rural heath clinic provider are reimbursed according to the Texas Medical Reimbursement Methodology for physician services.

  Advance practice nurses and physician assistants may bill for serving as assistants-at-surgery when the procedure is covered for an assistant. Diagnostic services provided by advance practice nurses and physician assistants are billable to Medicaid.

Medicare

• Medicare coverage is limited to services that nurse practitioners, clinical nurse specialists and physician assistants are legally authorized to perform. All services must be in accordance with state law. Medicare providers are reimbursed at 85 percent the physician fee amount. The specialized nurses and physician assistants can bill Medicare for services during surgery only if the procedure calls for an assistant.

Commercial

• Commercial billing guidelines vary with the individual commercial health plans. Some plans are billed under the physician's name and others have a credentialing process in place. Because the guidelines vary, each carrier must be directly contacted for their guidelines.