Section 20-2-I - MEDICAL RECORDSA. The medical record, which documents the patient's course of treatment, is the responsibility of the provider and is the basis for determining medical necessity and for substantiating the service(s) rendered; therefore, failure to submit necessary or adequate documentation to support the services rendered may result in the services being disallowed. B. A medical provider may not charge any fee for completing a medical report or form required by the MWCC which is part of the required supporting documentation which accompanies a request for payment. The supporting documentation that is required to substantiate the medical treatment is included in the fee for service and does not warrant a separate fee as it is incidental to providing medical care. CPT code 99080 is appropriate for billing special reports beyond those required by this Fee Schedule and requested by the payer or their representatives. C. Medical records must be legible and include, as applicable:1. Initial office visit notes which document a history, physical examination, assessment and plan appropriate to the level of service indicated by the presenting injury/illness or treatment of the ongoing injury/illness;2. Progress notes which reflect patient complaints, objective findings, assessment of the problem, and plan of care or treatment;3. Copies of lab, x-ray, or other diagnostic tests that reflect current progress of the patient and/or response to therapy or treatment;4. Physical medicine/occupational therapy progress notes that reflect the patient's response to treatment/therapy;5. Operative reports, consultation notes with report, and/or dictated report; and6. Impairment rating (projected and actual) and anticipated maximum medical improvement (MMI) date.D. A plan of care should be included in the medical record and should address, as applicable, the following: 2. Degree of restoration anticipated;4. Specific therapies to be used;5. Frequency and duration of treatments to be provided;6. Anticipated return to work date; andE. Health care providers must submit copies of records and reports to payers upon request. Providers can facilitate the timely processing of claims and payment for services by submitting appropriate documentation to the payer when requested. Only those records for a specific date of injury are considered non-privileged as it relates to a workers' compensation injury. The employer/payer is not privileged to non-work related medical information.F. Providers must submit documentation for the following: 1. The initial office visit;2. A progress report if still treating after thirty (30) days;3. Evaluation for therapy services/treatment (P.T., O.T., C.M.T., O.M.T.);4. A progress report every thirty (30) days for therapy services/treatment (P.T., O.T., C.M.T., O.M.T.);5. An operative report or office note (if done in the office) for a surgical procedure;7. The anesthesia record for anesthesia services;8. A functional capacity or work hardening evaluation;9. When billing "By Report" (BR), a description of the service is required; this description should include an adequate definition or description of the nature, extent, and need for the procedure and the time, effort, and equipment necessary to provide the service;10. Whenever a modifier is used to describe an unusual circumstance; and11. Whenever the procedure code descriptors include a written report.G. Hospitals and other inpatient facilities must submit required documentation with the appropriate billing forms as follows:1. Admission history and physical;7. Other dictated reports; and8. Emergency room records. The Health Insurance Portability & Accountability Act (HIPAA) makes important exceptions concerning the disclosure of protected health information for workers' compensation purposes. For additional information, refer to the MWCC website (mwcc.ms.gov), or consult an attorney and/or the HIPAA resource site maintained by the U. S. Department of Health and Human Services (http://www.hhs.gov/ocr/privacy/ [File Link Not Available]).