Rule 23-203-9.6 - DocumentationA. Physicians are required to maintain auditable records that will verify any or all services provided and billed under the Medicaid program.1. Records must, be made available to representatives of the Division of Medicaid or Office of the Attorney General in substantiation of claims.2. Records must be maintained for a minimum of five (5) years in order to comply with all state and federal regulations and laws. Refer to Maintenance of Records Part 200, Chapter 1, Rule 1.3.B. It is expected that the initial psychiatric service provided to any beneficiary must be of an evaluative nature. Documentation of the evaluation must be in the case record and must include, at a minimum:1. Dates, including beginning and ending session times, and the amount of time spent,4. History of present illness,5. Past psychiatric history,7. List of the beneficiary's current medications including prescription, non-prescription and over-the-counter,8. Social and family history,9. Comprehensive mental health status examination,10. Treatment plan formulation/prognosis,11. Assessment of the patient's ability to adhere to the treatment plan,12. A multi-axial diagnosis,13. Identification of the clinical problems that are to be the focus of treatment,14. Treatment modalities and/or strategies that will be employed or are recommended to address each problem. If medications are prescribed, documentation must include the name of the drug, strength and dosage. The method of administration must be included for injectable medications. Medication prescriptions must be identified as issued in writing, electronically, or by telephone, and15. The signature of the person who provided and documented the service. Any note that is "signed" by computer must be initialed by hand.C. A treatment plan must be developed and implemented for each beneficiary no later than the date of the third (3rd) therapy session. 1. The treatment plan must include, at a minimum: a) A multi-axial diagnosis, b) Identification of the beneficiaries' and/or family's strengths, c) Identification of the clinical problems, or areas of need, that is to be the focus of treatment, d) Treatment goals for each identified problem, e) Treatment objectives that represent incremental progress towards goals, coupled with target dates for their achievement, f) Specific treatment modalities and/or strategies that will be employed to reach each objective, and g) Date of implementation and signatures of the provider and the beneficiary or parent/legal guardian.2. Treatment plans must be kept in the case record and must be reviewed and revised as needed, or at least every three (3) months. Each review must be verified by the dated signatures of the provider and beneficiary/parent/legal guardian. The physician, nurse practitioner, psychologist, and clinical social worker must sign the treatment plan for the services each will provide to the beneficiary.D. A clinical note for each therapeutic service provided must be in the case record and must: 1. Include the date of service, type of service provided, the length of time spent delivering the service, who received or participated in it, as well as a brief summary of what transpired. If medications are prescribed, documentation must include the name of the drug, strength and dosage. The method of administration must be included for injectable medications. Medication prescriptions must be identified as issued in writing, electronically, or by telephone.2. Indicate whether Evaluation and Management services are provided.3. Relate to the problems identified in clinical record.4. Identify whether the service occurs in an inpatient or outpatient setting.5. Be authenticated by the signature of the person who provided and documented the service. Any note that is "signed" by computer must be initialed by hand.23 Miss. Code. R. 203-9.6
Miss. Code Ann. § 43-13-121