130 CMR, § 433.409 - Recordkeeping (Medical Records) Requirements
(A) Payment for any service listed in 130 CMR
433.000 is conditioned upon its full and complete documentation in the member's
medical record. Payment for maintaining the member's medical record is included
in the fee for the service.
(B) In
order for a medical record to document completely a service or services to a
member, that record must set forth the nature, extent, quality, and necessity
of care provided to the member. When the information contained in a member's
medical record is not sufficient to document the service for which payment is
claimed by the provider, the MassHealth agency will disallow payment for the
claimed service.
(C) The MassHealth
agency may at its discretion request, and upon such request the physician must
provide, any and all medical records of members corresponding to or documenting
the services claimed, in accordance with M.G.L. c. 118E, § 38, and
130 CMR
450.205: Recordkeeping and
Disclosure. The MassHealth agency may produce, or at its option may
require the physician to produce, photocopies of medical records instead of
actual records when compliance with 130 CMR 433.409(C) would otherwise result
in removal of medical records from the physician's office or other place of
practice.
(D)
(1) Medical records corresponding to office,
home, nursing facility, hospital outpatient department, and emergency
department services provided to members must include the reason for the visit
and the data upon which the diagnostic impression or statement of the member's
problem is based, and must be sufficient to justify any further diagnostic
procedures, treatments, and recommendations for return visits or referrals.
Specifically, these medical records must include, but may not be limited to,
the following:
(a) the member's name and date
of birth;
(b) the date of each
service;
(c) the name and title of
the person performing the service, if the service is performed by someone other
than the physician claiming payment for the service;
(d) the member's medical history;
(e) the diagnosis or chief
complaint;
(f) clear indication of
all findings, whether positive or negative, on examination;
(g) any medications administered or
prescribed, including strength, dosage, and regimen;
(h) a description of any treatment
given;
(i) recommendations for
additional treatments or consultations, when applicable;
(j) any medical goods or supplies dispensed
or prescribed;
(k) any tests
administered and their results; and
(l) for members younger than 21 years old who
are being treated by a physician or psychiatric clinical nurse specialist, a
CANS completed during the initial behavioral-health assessment and updated at
least once every 90 days thereafter.
(2) When additional information is necessary
to document the reason for the visit, the basis for diagnosis, or the
justification for future diagnostic procedures, treatments, or recommendations
for return visits or materials, such information must also be contained in the
medical record. Basic data collected during previous visits (for example,
identifying data, chief complaint, or history) need not be repeated in the
member's medical record for subsequent visits. However, data that fully
document the nature, extent, quality, and necessity of care provided to a
member must be included for each date of service or service code claimed for
payment, along with any data that update the member's medical
course.
(E) For inpatient
visit services provided in acute, chronic, or rehabilitation hospitals, there
must be an entry in the hospital medical record corresponding to and
substantiating each hospital visit claimed for payment. An inpatient medical
record will be deemed to document services provided to members and billed to
the MassHealth agency if it conforms to and satisfies the medical record
requirements set forth in 105 CMR 130.000: Licensure of
Hospitals. The physician claiming payment for any hospital inpatient
visit service is responsible for the adequacy of the medical record documenting
such service. The physician claiming payment for an initial hospital visit must
sign the entry in the hospital medical record that documents the findings of
the comprehensive history and physical examination.
(F) Additional medical record requirements
for radiology, psychiatry, and other services can be found in the applicable
sections of 130 CMR 433.000.
(G)
Compliance with the medical record requirements set forth in, referred to in,
or deemed applicable to 130 CMR 433.000 will be determined by a peer-review
group designated by the MassHealth agency as set forth in
130 CMR
450.206: Determination of Compliance
with Medical Standards. The MassHealth agency will refuse to pay or,
if payment has been made, will consider such payment to be an overpayment as
defined in
130 CMR 450.235:
Overpayments subject to recovery, for any claim that does not
comply with the medical record requirements established or referred to in 130
CMR 433.000. Such medical record requirements constitute the standard against
which the adequacy of records will be measured for physician services, as set
forth in
130 CMR
450.205(B).
Notes
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