23 Miss. Code. R. 216-1.5 - Documentation Requirements

A. Dialysis providers must maintain auditable records that substantiate the dialysis services provided.

B. The physician or qualified healthcare professional's documentation in the medical record must include, but is not limited to, the following:

1. Dates of service,

2. Monthly face-to-face evaluation of the beneficiary's current health status, medical condition, provider findings and appropriateness of the treatment plan,

3. Mode of dialysis and treatment plan,

4. All treatments, medications, biologicals, lab tests and other studies both included and excluded in the ESRD PPS rate, and

5. A legible signature of the physician or qualified healthcare professional with documented credentials to support the service rendered and date of entry.

C. If more than one (1) face-to-face physician or qualified healthcare professional visit is required within a month the:

1. Physician or qualified healthcare professional's documentation must support the medical necessity for the visit.

2. Interdisciplinary team documentation cannot be used to substantiate billing a physician or qualified healthcare professional's face-to-face visit.

D. The dialysis facility's record must include, but is not limited to, the following:

1. Dates of service,

2. Current annual evaluation including age and gender-appropriate history and physical examination documented by a physician including all pertinent lab and diagnostic procedures,

3. Individualized treatment notes which must include documentation verifying each face-to-face physician visit,

4. Beneficiary assessment in accordance with 42 CFR § 494.80,

5. Mode of dialysis and treatment plan,

6. All treatments, medications, biologicals, lab tests and other studies both included and excluded in the ESRD PPS rate,

7. A written plan of care prepared and reviewed monthly by an interdisciplinary team that includes the beneficiary's physician and other healthcare professionals, as appropriate, familiar with the beneficiary's condition, and

8. A legible signature of the physician or healthcare professional with documented credentials to support the service rendered and date of entry.

Notes

23 Miss. Code. R. 216-1.5

Miss. Code Ann. § 43-13-121.

Revised to correspond with SPA 14-003 (eff. 01/01/2014) eff. 05/01/2014.