CSHCN 2008 > Provider Enrollment and Responsibilities > Provider Responsibilities

   
 

3.2 Provider Responsibilities

3.2.1 General Medical Record Documentation Requirements

TMHP routinely performs a retrospective review of all providers. This review may include comparing services billed to the client's clinical record. The following requirements are general requirements for all providers. Any mandatory requirement not present in the client's medical record subjects the associated services to recoupment.

Note: This list is not all-inclusive. Additional and more specific requirements may apply to special services areas.

Requirement
Mandatory/Desirable

All entries are legible to individuals other than the author, dated (month, day, and year), and signed by the performing provider.

Mandatory

Each page of the medical record documents the client's name and CSHCN Services Program client identification number.

Mandatory

Allergies and adverse reactions (including immunization reactions) are prominently noted in the record.

Mandatory

The selection of evaluation and management codes (levels of service) is supported by the client's clinical record documentation. The American Medical Association's (AMA's) Current Procedural Terminology (CPT) descriptors of key/contributory components with level of service descriptions are used to evaluate the selection of levels of service.

Mandatory

Necessary follow-up visits specify the time of return by at least the week or month.

Mandatory

The history and physical documents the presenting complaint with appropriate subjective and objective information, e.g., medical and surgical history, current medications and supplements, family history, social history, diet, pertinent physical examination measurements and findings, etc.

Mandatory

The services provided are clearly documented in the medical record with all pertinent information regarding the client's condition to substantiate the need for the services.

Mandatory

Medically necessary diagnostic lab and X-ray results are included in the medical record, and abnormal findings include an explicit notation of follow-up plans.

Mandatory

Unresolved problems are noted in the record.

Mandatory

Immunizations are noted in the record as complete or up-to-date.

Mandatory

Personal data includes address, employer, home and work telephone numbers, sex, marital status, and emergency contacts.

Desirable


Texas Medicaid & Healthcare Partnership
CPT only copyright 2007 American Medical Association. All rights reserved.
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