Iowa Admin. Code r. 441-79.3 - Maintenance of records by providers of service
A provider of a service that is charged to the medical assistance program shall maintain complete and legible records as required in this rule. Failure to maintain records or failure to make records available to the department or to its authorized representative timely upon request shall result in claim denial or recoupment.
(1)
Financial (fiscal)
records.
a. A provider of service
shall maintain records as necessary to:
(1)
Support the determination of the provider's reimbursement rate under the
medical assistance program; and
(2)
Support each item of service for which a charge is made to the medical
assistance program. These records include financial records and other records
as may be necessary for reporting and accountability.
b. A financial record does not constitute a
medical record.
(2)
Medical (clinical) records. A provider of service shall
maintain complete and legible medical records for each service for which a
charge is made to the medical assistance program. Required records shall
include any records required to maintain the provider's license in good
standing.
a.
Definition.
"Medical record" (also called "clinical record") means a tangible history that
provides evidence of:
(1) The provision of
each service and each activity billed to the program; and
(2) First and last name of the member
receiving the service.
b.
Purpose. The medical record shall provide evidence that the
service provided is:
(1) Medically
necessary;
(2) Consistent with the
diagnosis of the member's condition; and
(3) Consistent with professionally recognized
standards of care.
c.
Components.
(1)
Identification. Each page or separate electronic document of the medical record
shall contain the member's first and last name. In the case of electronic
documents, the member's first and last name must appear on each screen when
viewed electronically and on each page when printed. As part of the medical
record, the medical assistance identification number and the date of birth must
also be identified and associated with the member's first and last
name.
(2) Basis for service-general
rule. General requirements for all services are listed herein. For the
application of these requirements to specific services, see paragraph
79.3(2)"d." The medical record shall reflect the reason for
performing the service or activity, substantiate medical necessity, and
demonstrate the level of care associated with the service. The medical record
shall include the items specified below unless the listed item is not routinely
received or created in connection with a particular service or activity and is
not required to document the reason for performing the service or activity, the
medical necessity of the service or activity, or the level of care associated
with the service or activity:
1. The member's
complaint, symptoms, and diagnosis.
2. The member's medical or social
history.
3. Examination
findings.
4. Diagnostic test
reports, laboratory test results, or X-ray reports.
5. Goals or needs identified in the member's
plan of care.
6. Physician orders
and any prior authorizations required for Medicaid payment.
7. Medication records, pharmacy records for
prescriptions, or providers' orders.
8. Related professional consultation
reports.
9. Progress or status
notes for the services or activities provided.
10. All forms required by the department as a
condition of payment for the services provided.
11. Any treatment plan, care plan, service
plan, individual health plan, behavioral intervention plan, or individualized
education program.
12. The
provider's assessment, clinical impression, diagnosis, or narrative, including
the complete date thereof and the identity of the person performing the
assessment, clinical impression, diagnosis, or narrative.
13. Any additional documentation necessary to
demonstrate the medical necessity of the service provided or otherwise required
for Medicaid payment.
(3)
Service documentation. The record for each service provided shall include
information necessary to substantiate that the service was provided. Unless
otherwise indicated below, the provider may document the services in any format
so long as the documentation adequately substantiates the medical necessity and
that the services were rendered. The service record shall include the
following:
1. The specific procedures or
treatments performed.
2. The
complete date of the service, including the beginning and ending date if the
service is rendered over more than one day.
3. The complete time of the service,
including the beginning and ending time if the service is billed on a
time-related basis. For those non-time-related services billed using Current
Procedural Terminology (CPT) codes, the total time of the service shall be
recorded, rather than the beginning and ending time.
4. The location where the service was
provided if otherwise required on the billing form or in 441-paragraph
77.30(5)"c" or "d," 441-paragraph
77.33(6)"d," 441-paragraph 77.34(5)"d,"
441-paragraph 77.37(15)"d," 441-paragraph
77.39(13)"e," 441-paragraph 77.39(14)"d,"
441-paragraph 77.46(5)"i," or 441-subparagraph
78.9(10)"a"(1).
5.
Medication administration record (MAR). The name, dosage, and route of
administration of any medication dispensed or administered as part of the
service.
6. Mileage log. The name,
date, purpose of the trip, and total miles for transportation provided as part
of the service.
7. Narrative
description of any incidents or illnesses or unusual or atypical occurrences
that occur during service provision.
8. Any supplies dispensed as part of the
service.
9. The first and last name
and professional credentials, if any, of the person providing the
service.
10. The signature of the
person providing the service, or the initials of the person providing the
service if a signature log indicates the person's identity.
11. For 24-hour care, documentation for every
shift of the services provided.
(4) Outcome of service. The medical record
shall indicate the member's progress in response to the services rendered,
including any changes in treatment, alteration of the plan of care, or revision
of the diagnosis.
d.
Basis for service requirements for specific services. The
health care provider should include all records and documentation that
substantiate the services provided to the member and all information necessary
to allow accurate adjudication of the claim. Additionally, documentation
requirements must meet the professional standards pertaining to the service
provided. The medical record for the following services must include, but is
not limited to, the items specified below (unless the listed item is not
routinely received or created in connection with the particular service or
activity and is not required to document the reason for performing the service
or activity, its medical necessity, or the level of care associated with it).
(1) Physician (MD and DO) services:
1. Service or office notes or
narratives.
2. Procedure,
laboratory, or test orders and results.
(2) Pharmacy services:
1. Prescriptions.
2. Nursing facility physician
order.
3. Telephone
order.
4. Pharmacy notes.
5. Prior authorization
documentation.
(3)
Dentist services:
1. Treatment
notes.
2. Anesthesia notes and
records.
3.
Prescriptions.
(4)
Podiatrist services:
1. Service or office
notes or narratives.
2. Certifying
physician statement.
3.
Prescription or order form.
(5) Certified registered nurse anesthetist
services:
1. Service notes or
narratives.
2. Preanesthesia
physical examination report.
3.
Operative report.
4. Anesthesia
record.
5. Prescriptions.
(6) Other advanced registered
nurse practitioner services:
1. Service or
office notes or narratives.
2.
Procedure, laboratory, or test orders and results.
3. Other service documentation as
applicable.
(7)
Optometrist and optician services:
1. Notes or
narratives supporting eye examinations, medical services, and auxiliary
procedures.
2. Original
prescription or updated prescriptions for corrective lenses or contact
lenses.
3. Prior authorization
documentation.
(8)
Psychologist services:
1. Service or office
psychotherapy notes or narratives.
2. Psychological examination report and
notes.
3. Other service
documentation as applicable.
(9) Clinic services:
1. Service or office notes or
narratives.
2. Procedure,
laboratory, or test orders and results.
3. Nurses' notes.
4. Prescriptions.
5. Medication administration
records.
(10) Services
provided by rural health clinics or federally qualified health centers:
1. Service or office notes or
narratives.
2. Form 470-2942,
Prenatal Risk Assessment.
3.
Procedure, laboratory, or test orders and results.
4. Immunization records.
(11) Services provided by community mental
health centers:
1. Service referral
documentation.
2. Initial
evaluation.
3. Individual treatment
plan.
4. Service or office notes or
narratives.
5. Narratives related
to the peer review process and peer review activities related to a member's
treatment.
6. Written plan for
accessing emergency services.
7.
Other service documentation as applicable.
(12) Screening center services:
1. Service or office notes or
narratives.
2. Immunization
records.
3. Laboratory
reports.
4. Results of health,
vision, or hearing screenings.
(13) Family planning services:
1. Service or office notes or
narratives.
2. Procedure,
laboratory, or test orders and results.
3. Nurses' notes.
4. Immunization records.
5. Consent forms.
6. Prescriptions.
7. Medication administration
records.
(14) Maternal
health center services:
1. Service or office
notes or narratives.
2. Procedure,
laboratory, or test orders and results.
3. Form 470-2942, Prenatal Risk
Assessment.
(15) Birthing
center services:
1. Service or office notes or
narratives.
2. Form 470-2942,
Prenatal Risk Assessment.
(16) Ambulatory surgical center services:
1. Service notes or narratives (history and
physical, consultation, operative report, discharge summary).
2. Physician orders.
3. Consent forms.
4. Anesthesia records.
5. Pathology reports.
6. Laboratory and X-ray reports.
(17) Hospital services:
1. Physician orders.
2. Service notes or narratives (history and
physical, consultation, operative report, discharge summary).
3. Progress or status notes.
4. Diagnostic procedures, including
laboratory and X-ray reports.
5.
Pathology reports.
6. Anesthesia
records.
7. Medication
administration records.
(18) State mental hospital services:
1. Service referral documentation.
2. Resident assessment and initial
evaluation.
3. Individual
comprehensive treatment plan.
4.
Service notes or narratives (history and physical, therapy records, discharge
summary).
5. Form 470-0042, Case
Activity Report.
6. Medication
administration records.
(19) Services provided by skilled nursing
facilities, nursing facilities, and nursing facilities for persons with mental
illness:
1. Physician orders.
2. Progress or status notes.
3. Service notes or narratives.
4. Procedure, laboratory, or test orders and
results.
5. Nurses'
notes.
6. Physical therapy,
occupational therapy, and speech therapy notes.
7. Medication administration
records.
8. Form 470-0042, Case
Activity Report.
(20)
Services provided by intermediate care facilities for persons with mental
retardation:
1. Physician orders.
2. Progress or status notes.
3. Preliminary evaluation.
4. Comprehensive functional
assessment.
5. Individual program
plan.
6. Form 470-0374, Resident
Care Agreement.
7. Program
documentation.
8. Medication
administration records.
9. Nurses'
notes.
10. Form 470-0042, Case
Activity Report.
(21)
Services provided by psychiatric medical institutions for children:
1. Physician orders or court
orders.
2. Independent
assessment.
3. Individual treatment
plan.
4. Service notes or
narratives (history and physical, therapy records, discharge
summary).
5. Form 470-0042, Case
Activity Report.
6. Medication
administration records.
(22) Hospice services:
1. Physician certifications for hospice
care.
2. Form 470-2618, Election of
Medicaid Hospice Benefit.
3. Form
470-2619, Revocation of Medicaid Hospice Benefit.
4. Plan of care.
5. Physician orders.
6. Progress or status notes.
7. Service notes or narratives.
8. Medication administration
records.
9.
Prescriptions.
(23)
Services provided by rehabilitation agencies:
1. Physician orders.
2. Initial certification, recertifications,
and treatment plans.
3. Narratives
from treatment sessions.
4.
Treatment and daily progress or status notes and forms.
(24) Home- and community-based habilitation
services:
1. Notice of decision for service
authorization.
2. Service plan
(initial and subsequent).
3.
Service notes or narratives.
4.
Other service documentation as applicable.
(25) Behavioral health intervention:
1. Order for services.
2. Comprehensive treatment or service plan
(initial and subsequent).
3.
Service notes or narratives.
4.
Other service documentation as applicable.
(26) Services provided by area education
agencies and local education agencies:
1.
Service notes or narratives.
2.
Individualized education program (IEP).
3. Individual health plan (IHP).
4. Behavioral intervention plan.
(27) Home health agency services:
1. Plan of care or plan of
treatment.
2. Certifications and
recertifications.
3. Service notes
or narratives.
4. Physician, nurse
practitioner, physician assistant, or clinical nurse specialist orders or
medical orders.
(28)
Services provided by independent laboratories:
1. Laboratory reports.
2. Physician order for each laboratory
test.
(29) Ambulance
services:
1. Documentation on the claim or run
report supporting medical necessity of the transport.
2. Documentation supporting mileage
billed.
(30) Services of
lead investigation agencies:
1. Service notes
or narratives.
2. Child's lead
level logs (including laboratory results).
3. Written investigation reports to family,
owner of building, child's medical provider, and local childhood lead poisoning
prevention program.
4. Health
education notes, including follow-up notes.
(31) Medical supplies:
1. Prescriptions.
2. Certificate of medical
necessity.
3. Prior authorization
documentation.
4. Medical equipment
invoice or receipt.
(32)
Orthopedic shoe dealer services:
1. Service
notes or narratives.
2.
Prescriptions.
3. Certifying
physician's statement.
(33) Case management services, including HCBS
case management services:
1. Notice of
decision for service authorization.
2. Service notes or narratives.
3. Social history.
4. Comprehensive service plan.
5. Reassessment of member needs.
6. Incident reports in accordance with
441-subrule 24.4(5).
7. Other
service documentation as applicable.
(34) Early access service coordinator
services:
1. Individualized family service
plan (IFSP).
2. Service notes or
narratives.
(35) Home-
and community-based waiver services, other than case management:
1. Notice of decision for service
authorization.
2. Service
plan.
3. Service logs, notes, or
narratives.
4. Mileage and
transportation logs.
5. Log of meal
delivery.
6. Invoices or
receipts.
7. Forms 470-3372, HCBS
Consumer-Directed Attendant Care Agreement, and 470-4389, Consumer-Directed
Attendant Care (CDAC) Service Record.
8. Other service documentation as
applicable.
(36) Physical
therapist services:
1. Physician order for
physical therapy.
2. Initial
physical therapy certification, recertifications, and treatment
plans.
3. Treatment notes and
forms.
4. Progress or status
notes.
(37) Chiropractor
services:
1. Service or office notes or
narratives.
2. X-ray
results.
(38) Hearing aid
dealer and audiologist services:
1. Physician
examinations and audiological testing (Form 470-0361, Sections A, B, and
C).
2. Waiver of informed
consent.
3. Prior authorization
documentation.
4. Service or office
notes or narratives.
(39)
Behavioral health services:
1.
Assessment.
2. Individual treatment
plan.
3. Service or office notes or
narratives.
4. Other service
documentation as applicable.
(40) Health home services:
1. Member's eligibility.
2. Comprehensive assessment.
3. Comprehensive care management plan for
members receiving chronic condition health home services, or comprehensive
person-centered care plan or service plan for members receiving integrated
health home services.
4. Care
coordination and health promotion plan.
5. Comprehensive transitional care plan,
including appropriate follow-up, if relevant.
6. Continuity of care document.
7. Documentation of member and family support
(including authorized representatives).
8. Documentation of referral to community and
social support services, if relevant.
9. Service notes or narratives.
10. Other documentation as applicable,
including as outlined in 441-subrule 78.53(5).
(41) Services of public health agencies:
1. Service or office notes or
narratives.
2. Immunization
records.
3. Results of communicable
disease testing.
(42)
Community-based neurobehavioral rehabilitation residential services and
community-based neurobehavioral rehabilitation intermittent services:
1. Department-approved standardized
neurobehavioral assessment tool.
2.
Community-based neurobehavioral treatment order.
3. Treatment plan.
4. Clinical records documenting diagnosis and
treatment history.
5. Progress or
status notes.
6. Service notes or
narratives.
7. Procedure,
laboratory, or test orders and results.
8. Therapy notes including but not limited to
occupational therapy, physical therapy, and speech-language pathology services
as applicable.
9. Medication
administration records.
10. Other
service documentation as applicable.
(43) Child care medical services:
1. Plan of care.
2. Certification and
recertification.
3. Service notes
or narratives.
4. Physician orders
or medical orders.
5. Abbreviation
list (a copy of the abbreviation list utilized within the member's
record).
6. If initials or
incomplete signatures are noted within the member's record, a signature log (a
typed listing of each provider's name, including initials, professional
credentials and title, followed by the individual provider's
signature).
(44) Subacute
mental health services.
1. Physician orders or
court orders.
2. Independent
assessment.
3. Individual treatment
plan.
4. Service notes or
narratives (history and physical, therapy records, discharge
summary).
5. Medication
administration records (residential services).
(45) Crisis response services, crisis
stabilization community-based services and crisis stabilization residential
services.
1. Assessment.
2. Individual stabilization plan.
3. Service notes or narratives (history and
physical, therapy records, discharge summary).
4. Medication administration records
(residential services).
e.
Corrections. A provider
may correct the medical record before submitting a claim for reimbursement.
(1) Corrections must be made or authorized by
the person who provided the service or by a person who has first-hand knowledge
of the service.
(2) A correction to
a medical record must not be written over or otherwise obliterate the original
entry. A single line may be drawn through erroneous information, keeping the
original entry legible. In the case of electronic records, the original
information must be retained and retrievable.
(3) Any correction must indicate the person
making the change and any other person authorizing the change, must be dated
and signed by the person making the change, and must be clearly connected with
the original entry in the record.
(4) If a correction made after a claim has
been submitted affects the accuracy or validity of the claim, an amended claim
must be submitted.
(3)
Maintenance requirement.
The provider shall maintain records as required by this rule:
a. During the time the member is receiving
services from the provider.
b. For
a minimum of five years from the date when a claim for the service was
submitted to the medical assistance program for payment.
c. As may be required by any licensing
authority or accrediting body associated with determining the provider's
qualifications.
This rule is intended to implement Iowa Code section 249A.4.
Notes
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