Section 424.409 - Recordkeeping (Medical Records) RequirementsPayment for any service listed in 130 CMR 424.000 is conditioned upon its full and complete documentation in the member's medical record.
(A) The medical record must contain sufficient data to fully document the nature, extent, and necessity of the care furnished to a member for each date of service claimed for payment, as well as any data that will update the member's medical course. The data maintained in the medical record must also be sufficient to justify any further diagnostic procedures, treatments, and recommendations for return visits or referrals.(B) Although basic data collected during previous visits (for example, identifying data, chief complaint, or history) do not need to be repeated in the member's medical record for subsequent visits, the medical records of each service provided by a podiatrist at any location must include, but not be limited to: (1) the member's name and date of birth;(2) the date of each service;(3) the reason for the visit;(4) the name and title of the person performing the service;(5) the member's medical history;(6) the diagnosis or chief complaint;(7) a clear indication of all findings, whether positive or negative, on examination;(8) any medications administered or prescribed, including strength, dosage, route, regimen, and duration of use;(9) a description of any treatment given;(10) recommendations for additional treatments or consultations, when applicable;(11) any medical goods or supplies dispensed or prescribed;(12) any tests administered and their results;(13) documentation of a treatment plan if subsequent visits are expected;(14) documentation, when applicable, that the member was informed of the necessity of a physician evaluation; and(15) MassHealth Shoe Medical Necessity Form (if applicable).Amended by Mass Register Issue 1319, eff. 8/12/2016.