Medicaid Compliant Documentation
Answered

I was recently audited by medicaid and all 40 of my claims were deemed "insufficient" in terms of what is called "General Medical Record Documentation Requirements"

I have placed a call to the auditor to obtain more specific information about what was missing that caused my notes to be deemed "insufficient" I am not certain whether they will return my call or answer my question. So.....

From the Medicaid Provider Manual, these are the topics that must be covered.  

As you read this list, has anyone treating clients on Medicaid actually been audited and passed the audit?  If so, I would really like (need) to know how you managed to provide all of this information in SimplePractice.  As it stands, if I cannot successful appeal the audit department's decision, I will be required to pay back several thousand dollars in claims that were initially paid.  

I need a system in place NOW that will allow me to provide all required information in compliant form.  

Any help and advice would be greatly appreciated

Here are the required items: 

  • (Mandatory) All entries are legible to individuals other than the author, dated (month, day, and year), and signed by the performing provider.
  • (Mandatory) Medicaid-enrolled providers must submit claims with their own TPI except when under the agreement of a substitute provider or locum tenens.
  • (Mandatory) Each page of the medical record documents the patient’s name and Texas Medicaid number.
  • (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) 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. 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 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.

17 comments

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    Heather Lee

    HI, I'm so sorry this happened to you. I just took a training on documentation and many of the things that were covered (and mandated by medicare audit) are not incorporated in Simple Practice. It's really scary, b/c I assumed that Simple Practice would ensure compliance! The trainers name is Beth Rontal, LICSW. 

     

    HI, I'm so sorry this happened to you. I just took a training on documentation and many of the things that were covered (and mandated by medicare audit) are not incorporated in Simple Practice. It's really scary, b/c I assumed that Simple Practice would ensure compliance! The trainers name is Beth Rontal, LICSW. 

     

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    Jorge W. Dionisio

    Hi

    The purpose of medicaid is not to get someone in trouble. It is simply to help therapists maximize their productivity and understand the requirements. I have been audited also and there were some changes I had to make.

    Hi

    The purpose of medicaid is not to get someone in trouble. It is simply to help therapists maximize their productivity and understand the requirements. I have been audited also and there were some changes I had to make.

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    Kristyn Roe

    I am new to Simple Practice and to Medicaid. The issue of Medicaid's very specific documentation requirements is a major concern for me. I was surprised to not see Medicaid compliant templates offered. Let's ask for those!

    I am new to Simple Practice and to Medicaid. The issue of Medicaid's very specific documentation requirements is a major concern for me. I was surprised to not see Medicaid compliant templates offered. Let's ask for those!

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    Mary Jean Carpenter

    Agreed, this is a huge gap in services that I was hoping this system provided.The EHR program that I had before ensured compliance if form was completed correctly (I don't know if I would  have switched over had I known). Let's create the forms and find a way to "share" with each other.

    Agreed, this is a huge gap in services that I was hoping this system provided.The EHR program that I had before ensured compliance if form was completed correctly (I don't know if I would  have switched over had I known). Let's create the forms and find a way to "share" with each other.

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    Rhonda L. Underwood

    Yes we need the patient's name on every page. That's common sense and an area that Simple Practice needs to fix immediately. An area in the heading would be a good place for them to add the location of service. 

    Yes we need the patient's name on every page. That's common sense and an area that Simple Practice needs to fix immediately. An area in the heading would be a good place for them to add the location of service. 

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    Patrick Wood

    Does SimplePractice have anything to say about this ????

    Does SimplePractice have anything to say about this ????

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    Gillian

    Hi Patrick, SimplePractice offers full customization on your Note and Form templates. We recommend adjusting your Note and Form templates to include the fields required by insurance payers, and reach out to insurance payers individually for clarification on their requirements. Rhonda, we're working on updating the print layout of progress notes to help make documentation easier to understand and more readable when responding to an audit.

    Hi Patrick, SimplePractice offers full customization on your Note and Form templates. We recommend adjusting your Note and Form templates to include the fields required by insurance payers, and reach out to insurance payers individually for clarification on their requirements. Rhonda, we're working on updating the print layout of progress notes to help make documentation easier to understand and more readable when responding to an audit.

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    Patrick Wood

    Gillian,

    I don't think the input note template is the issue. I think the printed report is the issue. Medicaid guidelines mandate that every page of a progress note have the date of service, client name, and page numbers (e.g. Page 1 of 2).  Users of Simple Practice are not able to modify the format or fields of the printed report.

    Gillian,

    I don't think the input note template is the issue. I think the printed report is the issue. Medicaid guidelines mandate that every page of a progress note have the date of service, client name, and page numbers (e.g. Page 1 of 2).  Users of Simple Practice are not able to modify the format or fields of the printed report.

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    Gillian

    Hi Patrick, thanks for clarifying - we're working on updating our print Progress Note layout, and welcome your feedback on our Ideas board here: https://simplepractice.uservoice.com/forums/918553/suggestions/36553009

    Hi Patrick, thanks for clarifying - we're working on updating our print Progress Note layout, and welcome your feedback on our Ideas board here: https://simplepractice.uservoice.com/forums/918553/suggestions/36553009

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    Danielle Mansfield

    Wow that is scary and agree with the updates needed for state mandated documentation, especially the name, date of service, and page number.

    Wow that is scary and agree with the updates needed for state mandated documentation, especially the name, date of service, and page number.

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    Gillian

    Hi Danielle, I'm happy to share that our updates to Progress Note print layouts have been completed, and all exported/printed Progress notes include pagination and the client's name on each page, as well as the Date of Service in a more readable format. 

    Hi Danielle, I'm happy to share that our updates to Progress Note print layouts have been completed, and all exported/printed Progress notes include pagination and the client's name on each page, as well as the Date of Service in a more readable format. 

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    Kristyn Roe

    Thank you Gillian and the SP development team! I am grateful for all efforts SP makes to help therapists be medicaid compliant. It is already very difficult to serve the underserved with all medicaid requires, so any support on the documentation end is very much appreciated!

    Thank you Gillian and the SP development team! I am grateful for all efforts SP makes to help therapists be medicaid compliant. It is already very difficult to serve the underserved with all medicaid requires, so any support on the documentation end is very much appreciated!

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    Cherie J. McGahee MSW, LCSW

    Did you have the exact session time documented in your notes? I just went through an audit and because the time on the note was generated by the scheduled time they are asking for me to pay back everything. I am beside myself about this. Is this something Simple Practice is aware of? Have others had this issue?

    Did you have the exact session time documented in your notes? I just went through an audit and because the time on the note was generated by the scheduled time they are asking for me to pay back everything. I am beside myself about this. Is this something Simple Practice is aware of? Have others had this issue?

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    Locke Curfman

    Cherie,

    My documentation was like yours, using the system generated time for each session. The problem I have is that I don’t know if I was penalized for that because the audit department has refused to provide me those details. I recently appealed my audit and I am waiting for their decision. I may know more then. Crazy.

    Cherie,

    My documentation was like yours, using the system generated time for each session. The problem I have is that I don’t know if I was penalized for that because the audit department has refused to provide me those details. I recently appealed my audit and I am waiting for their decision. I may know more then. Crazy.

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    Cherie J. McGahee MSW, LCSW

    I'm sorry you are dealing with that. Keep us updated and I will do the same so we can be in compliance from now on. I just recently appealed mine as well. 

    I'm sorry you are dealing with that. Keep us updated and I will do the same so we can be in compliance from now on. I just recently appealed mine as well. 

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    Ruth Trowbridge, MA, LPC

    I was considering getting recredentialed with Medicaid now that I am in private practice, but your comments have given me pause! Anyone having success and willing to recommend Medicaid for me?  

     

    I was considering getting recredentialed with Medicaid now that I am in private practice, but your comments have given me pause! Anyone having success and willing to recommend Medicaid for me?  

     

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    Anita Barnes

    I am  just getting started in my practice and I am using Simple Practice as well.  One issue I see is that as Medicaid Providers we need a way to get an actual signature (not just a checkbox).  I can't find a way on the forms I am creating to get the system to insert and actual online signature requirement besides the checkbox method.  I probably am missing this in the platform can anyone shed light on this issue?

    I am  just getting started in my practice and I am using Simple Practice as well.  One issue I see is that as Medicaid Providers we need a way to get an actual signature (not just a checkbox).  I can't find a way on the forms I am creating to get the system to insert and actual online signature requirement besides the checkbox method.  I probably am missing this in the platform can anyone shed light on this issue?