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.
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