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1.2.9 General Medical Record
Documentation Requirements
The Administrative Simplification Act of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 mandates the use of national coding and transaction standards. HIPAA requires that the American Medical Association's (AMA) Current Procedural Terminology (CPT) system be used to report professional services, including physician services. Correct use of CPT coding requires using the most specific code that matches the services provided based on the code's description. Providers must pay special attention to the standard CPT descriptions for the evaluation and management (E/M) services. The medical record must document the specific elements necessary to satisfy the criteria for the level of service as described in CPT. Reimbursement may be recouped when the medical record does not document that the level of service provided accurately matches the level of service claimed. Furthermore, the level of service provided and documented must be medically necessary based on the clinical situation and needs of the patient.
HHSC and TMHP routinely perform retrospective reviews of all providers. HHSC ultimately is responsible for Texas Medicaid utilization review activities. This review includes 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.
• Mandatory-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 patient's name and Texas Medicaid number.
•Mandatory-Allergies and adverse reactions (including immunization reactions) are prominently noted in the record.
•Mandatory-The selection of E/M codes (levels of service) is supported by the client's clinical record documentation. The AMA CPT descriptors of key/contributory components with level of service descriptions are used to evaluate the selection of levels of service.
•Mandatory-The history and physical documents the presenting complaint with appropriate subjective and objective information.
•Mandatory-The services provided are clearly documented in the medical record with all pertinent information regarding the patient's condition to substantiate the need and medical necessity for the services.
•Mandatory-Medically necessary diagnostic lab and X-ray results are included in the medical record and abnormal findings have an explicit notation of follow-up plans.
•Mandatory-Necessary follow-up visits specify time of return by at least the week or month.
•Mandatory-Unresolved problems are noted in the record.
•Desirable-Immunizations are noted in the record as complete or up-to-date.
•Desirable-Personal data includes address, employer, home/work telephone numbers, sex, marital status, and emergency contacts.
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