N.J. Admin. Code § 10:58-1.9

Current through Register Vol. 57, No. 1, January 6, 2025

Section 10:58-1.9 - Recordkeeping; general

(a) The certified nurse midwife shall keep such legible, individual records as are necessary to fully disclose the kind and extent of services provided, and the medical necessity for those services.

(b) Minimum documentation requirements for services performed by the certified nurse midwife shall include a clinical note or a progress note in the clinical record for each visit, which supports the procedure code or codes to be claimed. This information shall be available upon the request of the New Jersey Medicaid/NJ FamilyCare-Plan A fee-for-service programs or their agents.

(c) Documentation of services performed by the CNM shall include, at a minimum:

1. The date of service;

2. The name of the patient;

3. The patient complaint, reason for visit;

4. Subjective findings;

5. Objective findings;

6. An assessment;

7. A plan of care, including, but not limited to, any orders for laboratory work, prescriptions for medications;

8. The signature of the practitioner rendering the service; and

9. Other documentation appropriate to the procedure code being billed. See N.J.A.C. 10:58-3, HCPCS Codes.

(d) Written records in substantiation of the use of a given procedure code shall be available for review and/or inspection if requested by the New Jersey Medicaid/NJ FamilyCare-Plan A fee-for-service programs.

(e) Additional documentation requirements can be found at N.J.A.C. 10:49-9.4, 9.5 and 9.6.

(f) The CNM's involvement shall be clearly demonstrated in notes reflecting the practitioner's personal involvement with, or participation in, the service rendered.

N.J. Admin. Code § 10:58-1.9

Recodified from N.J.A.C. 10:58-1.8 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. 10:58-1.9, Recordkeeping; initial visit, recodified to N.J.A.C. 10:58-1.10.
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.204, effective 6/18/2001.
See: 33 N.J.R. 1160(a), 33 N.J.R. 2188(a).
In (b) and (d), added "/NJ FamilyCare-Plan A fee-for-service" following "Medicaid".