CLINICAL RECORDS
The following table contains general guidelines for clinical documentation that must be maintained by all providers except nursing facilities. Clinical records other than those listed may also be needed to clearly document all information pertinent to services that are rendered to beneficiaries. All providers must refer to their specific coverage policy in this manual for additional documentation requirements. The clinical record must be sufficiently detailed to allow reconstruction of what transpired for each service billed. All documentation for services provided must be signed and dated by the rendering health care professional.
For services that are time-specific according to the procedure code billed, providers must indicate in the medical record the actual begin time and end time of the particular service. For example, some Physical Medicine procedure codes specify per 15 minutes. If the procedure started at 3:00 p.m. and ended at 3:15 p.m., the begin time and end time must be recorded in the medical record.
The medical record must indicate the specific findings or results of diagnostic or therapeutic procedures. If an abbreviation, symbol, or other mark is used, it must be standard, widely accepted health care terminology. Symbols, marks, etc. unique to that provider must not be used.
Examples:
** When a test is performed, at a minimum, the test value for that beneficiary for that test must be noted. Additionally, the normal range of values for the testing methodology should be annotated in the record.
** When an x-ray is taken, the results or findings must be indicated. For example, a chest x-ray may indicate “no pulmonary edema present” or “no consolidation.”
** When a physical examination is performed, pertinent results or readings must appear.
** If blood pressure is taken, the actual reading must appear.
** If heart, lungs, eyes, etc. are checked, the results or findings must be detailed.
** Medical/surgical procedures performed must be sufficiently documented to allow another professional to reconstruct what transpired (e.g., “I-D” is not sufficient documentation).
** When a complete physical exam is rendered, the level of service must be fully documented.
** If private duty nursing is provided, the care provided during each hour must be fully detailed.
Hospitals must retain any clinical information required to comply with 42 CFR 482.24. A nursing facility must retain any clinical information required to comply with 42 CFR 483.75 and the plan of care must comply with 42 CFR 483.20(d). These regulations are available from MDHHS or Centers for Medicare & Medicaid Services (CMS). (Hospitals and nursing facilities should refer to the Reimbursement Appendix of their chapters in this manual for additional record keeping requirements.)
FISCAL RECORDS
The following fiscal records must be maintained:
** Copies of Remittance Advices (RA);
** PA requests and approvals for services and supplies (including managed care authorizations);
** Verification of medical necessity and the provider’s usual and customary charge for the noncovered service;
** Record of third-party payments; and
** Copies of purchase invoices for items offered or supplied to the beneficiary.
RECORD RETENTION
Providers must maintain, in English and in a legible manner, written or electronic records necessary to fully disclose and document the extent of services provided to beneficiaries. Necessary records include fiscal and clinical records as discussed below. Appointment books and any logs are also considered a necessary record if the provider renders a service that is time-specific according to the procedure code billed. Examples of services that are time-specific are psychological testing (per hour), medical psychotherapy (20-30 minutes), and vision orthoptic treatment (30 minutes). The records are to be retained for a period of not less than seven years from the DOS, regardless of change in ownership or termination of participation in Medicaid for any reason. This requirement is also extended to any subcontracted provider with which the provider has a business relationship.
ORDERS, PRESCRIPTIONS AND REFERRALS
Providers arranging or rendering services upon the order, prescription or referral of another provider (e.g., physician) must maintain that order, prescription and/or referral for a period of seven years.
BENEFICIARY IDENTIFICATION INFORMATION
Providers must retain the following beneficiary identification information in their records:
** Name
** Medicaid ID number
** Medical record number
** Address, including zip code
** Birth date
** Telephone number, if available
** Any private health insurance information for the beneficiary, if available
AVAILABILITY OF RECORDS
Providers are required to permit MDHHS personnel, or authorized agents, access to all information concerning any services that may be covered by Medicaid. This access does not require an authorization from the beneficiary because the purpose for the disclosure is permitted under the HIPAA Privacy rule. Health plans contracting with the MDHHS must be permitted access to all information relating to services reimbursed by the health plan.
Providers must, upon request from authorized agents of the state or federal government, make available for examination and photocopying all medical records, quality assurance documents, financial records, administrative records, and other documents and records that must be maintained. (Failure to make requested records available for examination and duplication and/or extraction through the method determined by authorized agents of the state or federal government may result in the provider’s
suspension and/or termination from Medicaid.) Records may only be released to other individuals if they have a release signed by the beneficiary authorizing access to his records or if the disclosure is for a permitted purpose under all applicable confidentiality laws.
CONFIDENTIALITY
MDHHS complies with HIPAA Privacy requirements and recognizes the concern for the confidential relationship between the provider and the beneficiary and protects this relationship using the minimum amount of information necessary for purposes directly related to the administration of Medicaid. All records are of a confidential nature and should not be released, other than to a beneficiary or his representative, unless the provider has a signed release from the beneficiary or the disclosure is for a permitted purpose under all applicable confidentiality laws (refer to the Availability of Records subsection of this chapter for additional information). Providers are bound to all HIPAA privacy and security requirements as federally mandated.
If the provider receives a court order, a subpoena, beneficiary request, or other authorized request for medical bills, payment, or claims adjudication information, the information should be released. At the same time, copies of the court order, subpoena, beneficiary request, other authorized request, and any additional information should be faxed to the MDHHS TPL Section. (Refer to the Directory Appendix for contact information.)
If there is a reason to suspect a duplicate payment has been or will be made, but the payment is not assigned, the provider should contact the TPL Section. TPL will make the necessary arrangements to collect the duplicate payment from the third-party source.
If the provider questions the appropriateness of releasing beneficiary records, he is encouraged to seek legal counsel before doing so.
