N.J. Admin. Code § 10:56-1.9

Current through Register Vol. 56, No. 12, June 17, 2024

Section 10:56-1.9 - Recordkeeping requirements

(a) Dentists shall maintain individual records which fully disclose the type and extent of services provided to the New Jersey Medicaid/NJ FamilyCare fee-for-service programs beneficiary, including detailing all services rendered for each encounter date. These records shall also fulfill the requirements of the New Jersey State Board of Dentistry as outlined in 13:30-8.7. The Medicaid/NJ FamilyCare Dental Claim Form (MC-10) shall not be an acceptable substitute. Such beneficiary records shall be maintained in the provider's office regardless of the actual place of service (dental office, long-term care facility, or hospital). These records shall be available for a minimum of seven years following the last date of service. The dentist shall also document services in facility records as required in (b) and (c) below. Such information shall be readily available to representatives of the New Jersey Medicaid/NJ FamilyCare fee-for-service programs or their agents as required.

1. The record shall include, but not be limited to, the following:

i. The name, address, and telephone number of the beneficiary, the beneficiary's date of birth and HSP (health services program) number, and, if a minor, name of parent(s) or guardian.

ii. Pertinent dental/medical history; and

iii. Detailed clinical evaluation data to include where applicable:

(1) Beneficiary's chief complaint;

(2) Diagnosis;

(3) Cavities;

(4) Missing teeth; and

(5) Abnormalities;

iv. Preoperative, progress, and postoperative radiographs, which shall be retained for a minimum of seven years following the last date of service. Professional liability insurance companies should be contacted for possible retention for longer periods. The number and type of radiographs shall be entered on the beneficiary's record. Postoperative radiographs shall be taken only when dentally necessary and only when such radiographs have diagnostic value.

v. Treatment plan with description of treatment rendered to include:

(1) Tooth number;

(2) Surfaces involved;

(3) Site and size of treatment area (lesion, laceration, fracture, and so forth);

(4) Materials used;

(5) Date(s) of service(s);

(6) Description of treatment or services rendered at each visit to include the name of the dentist or hygienist rendering it.

(7) All medications;

(8) Diagnostic laboratory and/or radiographic procedure(s) ordered, including the result(s);

(9) Copy of the dental prosthetic work authorization(s) (prescription(s)), and dental prosthetic laboratory receipt(s);

(10) Explanation for any duplication of services within one year (prosthetic services within seven and one-half years);

(11) Reasons for discontinuation of services (including attempts to complete treatment); and

(12) Referral and consultation reports.

(b) A complete description of treatment, as noted above, shall also be entered into a hospital's clinical records for any beneficiary treated at that facility. These entries shall also satisfy that specific hospital's regulations.

(c) A dentist who provides services for a nursing facility beneficiary (regardless of the place of service) shall, in addition to maintaining his or her own office records, provide the nursing facility with an entry for the beneficiary's clinical record that includes the following:

1. The results of an evaluation which will establish an admission record of the beneficiary's dental status.

i. If a current examination is required within six months of a previous examination performed by the same provider and billed to Medicaid/NJ FamilyCare, the results of the original examination shall be entered into the clinical record as the current dental status.

2. A time frame, established on an individual basis, for the next periodic evaluation of the beneficiary. The time frame shall be documented either at the time of evaluation or at the completion of treatment. For example, it may be entered on the clinical record for six months, one year, two years, three years, or any other time period that the attending dentist has established per his or her knowledge of the beneficiary and the beneficiary's dental status.

3. A record of dental treatment provided at each encounter.

i. A photocopy of the completed and signed Medicaid/NJ FamilyCare Dental Claim Form (MC-10) for evaluation and treatment will be accepted in lieu of a separate entry only if treatments (visits and description thereof) that preceded or followed the "dates of service" entered on the Medicaid/NJ FamilyCare Dental Claim Form (MC-10) are listed separately on the beneficiary's clinical record in addition to the recordkeeping requirements described in this section.

N.J. Admin. Code § 10:56-1.9

As amended, R.1981 d.219, eff. 7/9/1981 (to become operative August 1, 1981).
See: 12 N.J.R. 700(a), 13 N.J.R. 430(b).
(a): New text substituted for old; (a)1: "include but not be limited to" was "consist of."
(b) and (c) added.
Amended by R.1986 d.385, effective 9/22/1986.
See: 18 N.J.R. 1337(a), 18 N.J.R. 1958(a).
Prosthetic service changed from five to seven and one-half years.
Amended by R.1996 d.428, effective 9/16/1996.
See: 28 N.J.R. 3069(a), 28 N.J.R. 4243(a).
Recodified from N.J.A.C. 10:56-1.8 by R.1998 d.154, effective 2/27/1998 (operative March 1, 1998; to expire August 31, 1998).
See: 30 N.J.R. 1060(a).
Former N.J.A.C. 10:56-1.9, Utilization review, quality control, peer review and TAMI review, recodified to N.J.A.C. 10:56-1.10.
Adopted concurrent proposal, R.1998 d.487, effective 8/28/1998.
See: 30 N.J.R. 1060(a), 30 N.J.R. 3519(a).
Readopted the provisions of R.1998 d.154 without change.
Amended by R.2001 d.268, effective 8/6/2001.
See: 33 N.J.R. 1554(a), 33 N.J.R. 2666(b).
Rewrote the section.
Amended by R.2003 d.16, effective 1/6/2003.
See: 34 N.J.R. 2681(a), 35 N.J.R. 232(a).
Amended by R.2004 d.25, effective 1/20/2004.
See: 35 N.J.R. 4032(a), 36 N.J.R. 568(a).
In (c)1i, inserted reference to NJ FamilyCare.
Amended by R.2007 d.36, effective 2/5/2007.
See: 38 N.J.R. 3419(a), 39 N.J.R. 479(a).
In the introductory paragraph of (a), substituted "shall" for "are required to" and deleted "Services" following "Dental"; in (a)1iii, substituted "evaluation" for "examination"; in (a)1iv, inserted ", which shall be", substituted "shall" for "should" two times and substituted "only when such radiographs" for "must"; in (b), substituted "shall" for "must"; in the introductory paragraph of (c), substituted "beneficiary" for "recipient" and "beneficiary's" for "recipient's"; in (c)1 and (c)2, substituted "evaluation" for "examination" throughout; and in (c)3i, substituted "Medicaid/NJ FamilyCare Dental" for "Medicaid Dental Services" two times, substituted "evaluation" for "examination" and substituted "beneficiary's for "recipient's".