Iowa Admin. Code r. 441-79.3

Current through Register Vol. 46, No. 22, May 1, 2024

Rule 441-79.3 - Maintenance of records by providers of service

A provider of a service that is charged to the medical assistance program shall maintain complete and legible records as required in this rule. Failure to maintain records or failure to make records available to the department or to its authorized representative timely upon request shall result in claim denial or recoupment.

(1)Financial (fiscal) records.

a. A provider of service shall maintain records as necessary to:

(1) Support the determination of the provider's reimbursement rate under the medical assistance program; and

(2) Support each item of service for which a charge is made to the medical assistance program. These records include financial records and other records as may be necessary for reporting and accountability.

b. A financial record does not constitute a medical record.

(2)Medical (clinical) records. A provider of service shall maintain complete and legible medical records for each service for which a charge is made to the medical assistance program. Required records shall include any records required to maintain the provider's license in good standing.

a.Definition. "Medical record" (also called "clinical record") means a tangible history that provides evidence of:

(1) The provision of each service and each activity billed to the program; and

(2) First and last name of the member receiving the service.

b.Purpose. The medical record shall provide evidence that the service provided is:

(1) Medically necessary;

(2) Consistent with the diagnosis of the member's condition; and

(3) Consistent with professionally recognized standards of care.

c.Components.

(1) Identification. Each page or separate electronic document of the medical record shall contain the member's first and last name. In the case of electronic documents, the member's first and last name must appear on each screen when viewed electronically and on each page when printed. As part of the medical record, the medical assistance identification number and the date of birth must also be identified and associated with the member's first and last name.

(2) Basis for service-general rule. General requirements for all services are listed herein. For the application of these requirements to specific services, see paragraph 79.3(2)"d." The medical record shall reflect the reason for performing the service or activity, substantiate medical necessity, and demonstrate the level of care associated with the service. The medical record shall include the items specified below unless the listed item is not routinely received or created in connection with a particular service or activity and is not required to document the reason for performing the service or activity, the medical necessity of the service or activity, or the level of care associated with the service or activity:

1. The member's complaint, symptoms, and diagnosis.

2. The member's medical or social history.

3. Examination findings.

4. Diagnostic test reports, laboratory test results, or X-ray reports.

5. Goals or needs identified in the member's plan of care.

6. Physician orders and any prior authorizations required for Medicaid payment.

7. Medication records, pharmacy records for prescriptions, or providers' orders.

8. Related professional consultation reports.

9. Progress or status notes for the services or activities provided.

10. All forms required by the department as a condition of payment for the services provided.

11. Any treatment plan, care plan, service plan, individual health plan, behavioral intervention plan, or individualized education program.

12. The provider's assessment, clinical impression, diagnosis, or narrative, including the complete date thereof and the identity of the person performing the assessment, clinical impression, diagnosis, or narrative.

13. Any additional documentation necessary to demonstrate the medical necessity of the service provided or otherwise required for Medicaid payment.

(3) Service documentation. The record for each service provided shall include information necessary to substantiate that the service was provided. Unless otherwise indicated below, the provider may document the services in any format so long as the documentation adequately substantiates the medical necessity and that the services were rendered. The service record shall include the following:

1. The specific procedures or treatments performed.

2. The complete date of the service, including the beginning and ending date if the service is rendered over more than one day.

3. The complete time of the service, including the beginning and ending time if the service is billed on a time-related basis. For those non-time-related services billed using Current Procedural Terminology (CPT) codes, the total time of the service shall be recorded, rather than the beginning and ending time.

4. The location where the service was provided if otherwise required on the billing form or in 441-paragraph 77.30(5)"c" or "d," 441-paragraph 77.33(6)"d," 441-paragraph 77.34(5)"d," 441-paragraph 77.37(15)"d," 441-paragraph 77.39(13)"e," 441-paragraph 77.39(14)"d," 441-paragraph 77.46(5)"i," or 441-subparagraph 78.9(10)"a"(1).

5. Medication administration record (MAR). The name, dosage, and route of administration of any medication dispensed or administered as part of the service.

6. Mileage log. The name, date, purpose of the trip, and total miles for transportation provided as part of the service.

7. Narrative description of any incidents or illnesses or unusual or atypical occurrences that occur during service provision.

8. Any supplies dispensed as part of the service.

9. The first and last name and professional credentials, if any, of the person providing the service.

10. The signature of the person providing the service, or the initials of the person providing the service if a signature log indicates the person's identity.

11. For 24-hour care, documentation for every shift of the services provided.

(4) Outcome of service. The medical record shall indicate the member's progress in response to the services rendered, including any changes in treatment, alteration of the plan of care, or revision of the diagnosis.

d.Basis for service requirements for specific services. The health care provider should include all records and documentation that substantiate the services provided to the member and all information necessary to allow accurate adjudication of the claim. Additionally, documentation requirements must meet the professional standards pertaining to the service provided. The medical record for the following services must include, but is not limited to, the items specified below (unless the listed item is not routinely received or created in connection with the particular service or activity and is not required to document the reason for performing the service or activity, its medical necessity, or the level of care associated with it).

(1) Physician (MD and DO) services:

1. Service or office notes or narratives.

2. Procedure, laboratory, or test orders and results.

(2) Pharmacy services:

1. Prescriptions.

2. Nursing facility physician order.

3. Telephone order.

4. Pharmacy notes.

5. Prior authorization documentation.

(3) Dentist services:

1. Treatment notes.

2. Anesthesia notes and records.

3. Prescriptions.

(4) Podiatrist services:

1. Service or office notes or narratives.

2. Certifying physician statement.

3. Prescription or order form.

(5) Certified registered nurse anesthetist services:

1. Service notes or narratives.

2. Preanesthesia physical examination report.

3. Operative report.

4. Anesthesia record.

5. Prescriptions.

(6) Other advanced registered nurse practitioner services:

1. Service or office notes or narratives.

2. Procedure, laboratory, or test orders and results.

3. Other service documentation as applicable.

(7) Optometrist and optician services:

1. Notes or narratives supporting eye examinations, medical services, and auxiliary procedures.

2. Original prescription or updated prescriptions for corrective lenses or contact lenses.

3. Prior authorization documentation.

(8) Psychologist services:

1. Service or office psychotherapy notes or narratives.

2. Psychological examination report and notes.

3. Other service documentation as applicable.

(9) Clinic services:

1. Service or office notes or narratives.

2. Procedure, laboratory, or test orders and results.

3. Nurses' notes.

4. Prescriptions.

5. Medication administration records.

(10) Services provided by rural health clinics or federally qualified health centers:

1. Service or office notes or narratives.

2. Form 470-2942, Prenatal Risk Assessment.

3. Procedure, laboratory, or test orders and results.

4. Immunization records.

(11) Services provided by community mental health centers:

1. Service referral documentation.

2. Initial evaluation.

3. Individual treatment plan.

4. Service or office notes or narratives.

5. Narratives related to the peer review process and peer review activities related to a member's treatment.

6. Written plan for accessing emergency services.

7. Other service documentation as applicable.

(12) Screening center services:

1. Service or office notes or narratives.

2. Immunization records.

3. Laboratory reports.

4. Results of health, vision, or hearing screenings.

(13) Family planning services:

1. Service or office notes or narratives.

2. Procedure, laboratory, or test orders and results.

3. Nurses' notes.

4. Immunization records.

5. Consent forms.

6. Prescriptions.

7. Medication administration records.

(14) Maternal health center services:

1. Service or office notes or narratives.

2. Procedure, laboratory, or test orders and results.

3. Form 470-2942, Prenatal Risk Assessment.

(15) Birthing center services:

1. Service or office notes or narratives.

2. Form 470-2942, Prenatal Risk Assessment.

(16) Ambulatory surgical center services:

1. Service notes or narratives (history and physical, consultation, operative report, discharge summary).

2. Physician orders.

3. Consent forms.

4. Anesthesia records.

5. Pathology reports.

6. Laboratory and X-ray reports.

(17) Hospital services:

1. Physician orders.

2. Service notes or narratives (history and physical, consultation, operative report, discharge summary).

3. Progress or status notes.

4. Diagnostic procedures, including laboratory and X-ray reports.

5. Pathology reports.

6. Anesthesia records.

7. Medication administration records.

(18) State mental hospital services:

1. Service referral documentation.

2. Resident assessment and initial evaluation.

3. Individual comprehensive treatment plan.

4. Service notes or narratives (history and physical, therapy records, discharge summary).

5. Form 470-0042, Case Activity Report.

6. Medication administration records.

(19) Services provided by skilled nursing facilities, nursing facilities, and nursing facilities for persons with mental illness:

1. Physician orders.

2. Progress or status notes.

3. Service notes or narratives.

4. Procedure, laboratory, or test orders and results.

5. Nurses' notes.

6. Physical therapy, occupational therapy, and speech therapy notes.

7. Medication administration records.

8. Form 470-0042, Case Activity Report.

(20) Services provided by intermediate care facilities for persons with mental retardation:

1. Physician orders.

2. Progress or status notes.

3. Preliminary evaluation.

4. Comprehensive functional assessment.

5. Individual program plan.

6. Form 470-0374, Resident Care Agreement.

7. Program documentation.

8. Medication administration records.

9. Nurses' notes.

10. Form 470-0042, Case Activity Report.

(21) Services provided by psychiatric medical institutions for children:

1. Physician orders or court orders.

2. Independent assessment.

3. Individual treatment plan.

4. Service notes or narratives (history and physical, therapy records, discharge summary).

5. Form 470-0042, Case Activity Report.

6. Medication administration records.

(22) Hospice services:

1. Physician certifications for hospice care.

2. Form 470-2618, Election of Medicaid Hospice Benefit.

3. Form 470-2619, Revocation of Medicaid Hospice Benefit.

4. Plan of care.

5. Physician orders.

6. Progress or status notes.

7. Service notes or narratives.

8. Medication administration records.

9. Prescriptions.

(23) Services provided by rehabilitation agencies:

1. Physician orders.

2. Initial certification, recertifications, and treatment plans.

3. Narratives from treatment sessions.

4. Treatment and daily progress or status notes and forms.

(24) Home- and community-based habilitation services:

1. Notice of decision for service authorization.

2. Service plan (initial and subsequent).

3. Service notes or narratives.

4. Other service documentation as applicable.

(25) Behavioral health intervention:

1. Order for services.

2. Comprehensive treatment or service plan (initial and subsequent).

3. Service notes or narratives.

4. Other service documentation as applicable.

(26) Services provided by area education agencies and local education agencies:

1. Service notes or narratives.

2. Individualized education program (IEP).

3. Individual health plan (IHP).

4. Behavioral intervention plan.

(27) Home health agency services:

1. Plan of care or plan of treatment.

2. Certifications and recertifications.

3. Service notes or narratives.

4. Physician, nurse practitioner, physician assistant, or clinical nurse specialist orders or medical orders.

(28) Services provided by independent laboratories:

1. Laboratory reports.

2. Physician order for each laboratory test.

(29) Ambulance services:

1. Documentation on the claim or run report supporting medical necessity of the transport.

2. Documentation supporting mileage billed.

(30) Services of lead investigation agencies:

1. Service notes or narratives.

2. Child's lead level logs (including laboratory results).

3. Written investigation reports to family, owner of building, child's medical provider, and local childhood lead poisoning prevention program.

4. Health education notes, including follow-up notes.

(31) Medical supplies:

1. Prescriptions.

2. Certificate of medical necessity.

3. Prior authorization documentation.

4. Medical equipment invoice or receipt.

(32) Orthopedic shoe dealer services:

1. Service notes or narratives.

2. Prescriptions.

3. Certifying physician's statement.

(33) Case management services, including HCBS case management services:

1. Notice of decision for service authorization.

2. Service notes or narratives.

3. Social history.

4. Comprehensive service plan.

5. Reassessment of member needs.

6. Incident reports in accordance with 441-subrule 24.4(5).

7. Other service documentation as applicable.

(34) Early access service coordinator services:

1. Individualized family service plan (IFSP).

2. Service notes or narratives.

(35) Home- and community-based waiver services, other than case management:

1. Notice of decision for service authorization.

2. Service plan.

3. Service logs, notes, or narratives.

4. Mileage and transportation logs.

5. Log of meal delivery.

6. Invoices or receipts.

7. Forms 470-3372, HCBS Consumer-Directed Attendant Care Agreement, and 470-4389, Consumer-Directed Attendant Care (CDAC) Service Record.

8. Other service documentation as applicable.

(36) Physical therapist services:

1. Physician order for physical therapy.

2. Initial physical therapy certification, recertifications, and treatment plans.

3. Treatment notes and forms.

4. Progress or status notes.

(37) Chiropractor services:

1. Service or office notes or narratives.

2. X-ray results.

(38) Hearing aid dealer and audiologist services:

1. Physician examinations and audiological testing (Form 470-0361, Sections A, B, and C).

2. Waiver of informed consent.

3. Prior authorization documentation.

4. Service or office notes or narratives.

(39) Behavioral health services:

1. Assessment.

2. Individual treatment plan.

3. Service or office notes or narratives.

4. Other service documentation as applicable.

(40) Health home services:

1. Member's eligibility.

2. Comprehensive assessment.

3. Comprehensive care management plan for members receiving chronic condition health home services, or comprehensive person-centered care plan or service plan for members receiving integrated health home services.

4. Care coordination and health promotion plan.

5. Comprehensive transitional care plan, including appropriate follow-up, if relevant.

6. Continuity of care document.

7. Documentation of member and family support (including authorized representatives).

8. Documentation of referral to community and social support services, if relevant.

9. Service notes or narratives.

10. Other documentation as applicable, including as outlined in 441-subrule 78.53(5).

(41) Services of public health agencies:

1. Service or office notes or narratives.

2. Immunization records.

3. Results of communicable disease testing.

(42) Community-based neurobehavioral rehabilitation residential services and community-based neurobehavioral rehabilitation intermittent services:

1. Department-approved standardized neurobehavioral assessment tool.

2. Community-based neurobehavioral treatment order.

3. Treatment plan.

4. Clinical records documenting diagnosis and treatment history.

5. Progress or status notes.

6. Service notes or narratives.

7. Procedure, laboratory, or test orders and results.

8. Therapy notes including but not limited to occupational therapy, physical therapy, and speech-language pathology services as applicable.

9. Medication administration records.

10. Other service documentation as applicable.

(43) Child care medical services:

1. Plan of care.

2. Certification and recertification.

3. Service notes or narratives.

4. Physician orders or medical orders.

5. Abbreviation list (a copy of the abbreviation list utilized within the member's record).

6. If initials or incomplete signatures are noted within the member's record, a signature log (a typed listing of each provider's name, including initials, professional credentials and title, followed by the individual provider's signature).

(44) Subacute mental health services.

1. Physician orders or court orders.

2. Independent assessment.

3. Individual treatment plan.

4. Service notes or narratives (history and physical, therapy records, discharge summary).

5. Medication administration records (residential services).

(45) Crisis response services, crisis stabilization community-based services and crisis stabilization residential services.

1. Assessment.

2. Individual stabilization plan.

3. Service notes or narratives (history and physical, therapy records, discharge summary).

4. Medication administration records (residential services).

e.Corrections. A provider may correct the medical record before submitting a claim for reimbursement.

(1) Corrections must be made or authorized by the person who provided the service or by a person who has first-hand knowledge of the service.

(2) A correction to a medical record must not be written over or otherwise obliterate the original entry. A single line may be drawn through erroneous information, keeping the original entry legible. In the case of electronic records, the original information must be retained and retrievable.

(3) Any correction must indicate the person making the change and any other person authorizing the change, must be dated and signed by the person making the change, and must be clearly connected with the original entry in the record.

(4) If a correction made after a claim has been submitted affects the accuracy or validity of the claim, an amended claim must be submitted.

(3)Maintenance requirement. The provider shall maintain records as required by this rule:

a. During the time the member is receiving services from the provider.

b. For a minimum of five years from the date when a claim for the service was submitted to the medical assistance program for payment.

c. As may be required by any licensing authority or accrediting body associated with determining the provider's qualifications.

This rule is intended to implement Iowa Code section 249A.4.

Iowa Admin. Code r. 441-79.3

ARC 7957B, IAB 7/15/09, effective 7/1/09; ARC 8262B, IAB 11/4/09, effective 12/9/09; ARC 9440B, IAB 4/6/11, effective 4/1/11; ARC 9487B, IAB 5/4/11, effective 7/1/11; ARC 0198C, IAB 7/11/12, effective 7/1/12; ARC 0358C, IAB 10/3/12, effective 11/7/12; ARC 0711C, IAB 5/1/2013, effective 7/1/2013

Amended by IAB October 29, 2014/Volume XXXVII, Number 9, effective 1/1/2015

Amended by IAB January 06, 2016/Volume XXXVIII, Number 14, effective 2/10/2016

Amended by IAB October 11, 2017/Volume XL, Number 8, effective 10/1/2017

Amended by IAB January 3, 2018/Volume XL, Number 14, effective 2/7/2018

Amended by IAB March 28, 2018/Volume XL, Number 20, effective 7/1/2018

Amended by IAB November 6, 2019/Volume XLII, Number 10, effective 12/11/2019

Amended by IAB March 10, 2021/Volume XLIII, Number 19, effective 4/14/2021

Amended by IAB May 4, 2022/Volume XLIV, Number 22, effective 7/1/2022

Amended by IAB October 5, 2022/Volume XLV, Number 7, effective 9/16/2022