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December 2016 Texas Medicaid Provider Procedures Manual

Section 1: Provider Enrollment and Responsibilities : 1.6 Provider Responsibilities : 1.6.10 General Medical Record Documentation Requirements

The Administrative Simplification Act of HIPAA mandates the use of national coding and transaction standards. HIPAA requires that the American Medical Association’s (AMA) Current Procedural Terminology (CPT) system or the American Dental Association’s (ADA) Current Dental Terminology (CDT) system be used to report professional services, including physician and dental services. Correct use of CPT and CDT coding requires using the most specific procedure code that matches the services provided based on the procedure code’s description. Providers must pay special attention to the standard CPT descriptions for the evaluation and management 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.
Health-care documentation that is maintained by a provider in a client’s record can be maintained in a language other than English; however, when TMHP, HHSC, or any other state/federal agency requests a written record or conducts a documentation review, this health-care documentation must be provided in English and in a timely manner.
(Mandatory) Medicaid-enrolled providers must submit claims with their own TPI except when under the agreement of a substitute provider or locum tenens.
(Mandatory) A copy of the actual authorization from HHSC or its designee (e.g., TMHP) is maintained in the medical record for any item or service that requires prior authorization.
(Mandatory) The selection of evaluation and management codes (levels of service) is supported by the client’s clinical record documentation. Providers must follow either the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services published by CMS, when selecting the level of service provided.
(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.
An unenrolled provider that renders services and attempts to use the TPI of a provider who is enrolled in Medicaid will not be reimbursed for the services. During retrospective review, any services that were rendered by a provider that was not enrolled in Texas Medicaid and were billed using the provider identifier of a Medicaid-enrolled provider are subject to recoupment.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.