For purposes of this part, the following terms have the meanings given them.
"Physician directed clinic" means an entity with at least two physicians on staff which is enrolled in the medical assistance program to provide physician services.
"Physician's employee" means a nurse practitioner or physician assistant, mental health practitioner, or mental health professional.
"Physician service" means a medically necessary health service provided by or under the supervision of a physician.
Except for a physician service provided in a physician directed clinic or a long-term care facility, a physician service by a physician's employee must be under the supervision of the provider in order to be eligible for payment under the medical assistance program.
Physician service in a physician directed clinic must be provided under the supervision of a physician who is on the premises and who is a provider.
A physician service provided by a physician's employee in a long-term care facility is a covered service if provided under the direction of a physician who is a provider except as in items A to C.
The service is a certification made at the recipient's admission.
The service is to write a plan of care required by Code of Federal Regulations, title 42, part 456.
The service is a physician visit in a skilled nursing facility required by Code of Federal Regulations, title 42, section 405.1123 or a physician visit in an intermediate care facility required by Code of Federal Regulations, title 42, section 442.346. For purposes of this subpart, "physician visit" means the term specified in Code of Federal Regulations, title 42, sections 405.1123 and 442.346.
A weight reduction program requires prior authorization. It is a covered service only if the excess weight complicates a diagnosed medical condition or is life threatening. The weight reduction program must be prescribed and administered under the supervision of a physician.
Payment for a physician service to a recipient to evaluate the effectiveness of a drug prescribed in the recipient's plan of care is limited for each recipient to one service per week. The payment shall be made only for the evaluation of the effect of antipsychotic or antidepressant drugs.
The limitations and exclusions applicable to podiatry services under part 9505.0350, subparts 2 and 3, apply to comparable services furnished by a physician.
Payment for a physician visit to a long-term care facility is limited to once every 30 days per resident of the facility unless the medical necessity of additional visits is documented.
A laboratory service ordered by a physician is subject to the payment limitation of part 9505.0305, subpart 4. Furthermore, payment for a laboratory service performed in a physician's laboratory shall not exceed the amount paid for a similar service performed in an independent laboratory under part 9505.0305.
When a physician service is provided to more than one recipient who resides in the same long-term care facility by the same provider on the same day, payment for the provider's visit to the first recipient shall be according to part 9505.0445, item E, for the procedure code for the visit. The provider's visit on the same day to other recipients within the same long-term care facility must be billed with the multiple visit code established by the department. This subpart shall not apply to a provider's visit to provide an emergency service on the same day within the same long-term care facility if the emergency service could not have been scheduled consecutively with another recipient visit. If the provider visits other recipients in the same facility on the same day after providing an emergency service, the provider's visits must be billed with the multiple visit code.
The physician services in items A to E are not eligible for payment under the medical assistance program:
procedure to reverse voluntary sterilization;
surgery primarily for cosmetic purposes;
services of a surgical assistant; and
inpatient hospital visits when the physician has not had face-to-face contact with the recipient.
12 SR 624; 34 SR 1135
February 24, 2010