Documentation and Maintenance of Records

1
Documentation and Maintenance of Records

• What You Should Know and Why

Program Training For Medicaid Providers of Home
and Community Care Services Home and Community
Care Section N.C. Division of Medical Assistance
2
Learning Objectives

• At the conclusion of the presentation the learner
  will be able to do the following
• Identify three reasons why documentation is
  necessary.
• Identify three reasons why documentation matters.
• Identify the mandatory retention period for
  Medicaid records

3
Definition of Documentation

• The permanent recording of information properly
  identified as to time, place, circumstances and
  attribution.

4
Documentation Is Necessary Because Cont.

• It supports continuity of care
• It demonstrates quality care progress toward
  goals
• It establishes a contract between care partners

5
Documentation Is Necessary Because Cont.

• Record documentation is used by DMA to determine
  medical necessity and to verify that services
  were billed correctly. Individual policy
  requirements must also be met.

6
Documentation Is Necessary Because Cont.

• As stated in the NC DHHS provider Administrative
  Participation Agreement, providers have a
  responsibility to submit records related to
  services rendered to DMA when requested
• The Provider agrees that billings and reports
  related to services rendered shall be submitted
  in the format and frequency specified by the
  Department, any of its divisions and or its
  fiscal agent. Failure to file mandatory reports
  or required disclosures within the time frames
  established by Department rule or policy may
  result in suspension of payments and/or other
  enforcement actions.

7
Documentation Is Necessary Because Cont.

• Below are a few of the documentation principles
  that Medicaid has adopted from Medicare
• The health record must be complete and legible
• The documentation of each patient encounter must
  include the date and reason for the encounter as
  well as relevant history, physical examination
  findings, and prior diagnostic test results
  assessment clinical impression or diagnosis
  services delivered plan for care, including
  drugs and dosage prescribed or administered and
  legible signature of the observer
• The CPT, HCPCS, and ICD-9-CM codes reported on
  the health insurance claim form or billing
  statement must be supported by the documentation
  in the health record

8
Documentation Matters Because Cont.

• The Medicaid participation agreement stipulates
  the following
• That all claims shall be true, accurate, and
  complete and that services billed shall be
  personally furnished by Provider, its employees,
  or persons with whom the Provider has contracted
  to render services, under its direction.
• Failure to retain all records required to
  substantiate clinical appropriateness and/or
  medical necessity of services billed to Medicaid
  may result in provider sanctions, including but
  not limited to their NC Provider Administrative
  Participation Agreement being terminated.

9
Documentation is Just the Beginning

• The timeframes governing the length of time that
  Medicaid records must be maintained emphasizes
  the importance of accurate documentation.
• Providers responsibility for well documented
  records goes beyond their being an active
  provider.
• Read the June 2013 Medicaid Bulletin article
  entitled Maintaining the Security and
  Accessibility of Records after a provider Agency
  Closes for more helpful information.

10
Records Retention Requirements

• A providers obligation to maintain Medicaid
  records is independent from ongoing participation
  in the N.C Medicaid program and extends beyond
  the expiration or termination of the Agreement or
  contract.

11
Records Retention Requirements Cont.

• All Medicaid providers are responsible for
  maintaining custody of the records and
  documentation to support service provision and
  reimbursement of services by N.C, Medicaid for at
  least six years.

12
Consequences for Noncompliance

• Provider records may be subject to post-payment
  audits or investigations after an agency closes.

13
What if I Sell or Go Out of Business?

• If another provider takes over the functions of a
  closing entity, maintenance of the closing
  entity's records for the applicable beneficiaries
  may be transferred to the new provider, if the
  new provider agrees to accept custody of such
  records in writing and a copy of this agreement
  is provided to DMA upon request.

14
What If I Sell or Go Out of Business Cont.

• When the custody of records is not transferred,
  the closing providers should send copies of
  transitional documentation to the providers who
  will be serving the beneficiary for continuity of
  care. Consumer authorization should be obtained
  as necessary. Copies of records may be provided
  to the beneficiary directly for coordination of
  care.

15
Notification of Changes

• N.C. Medicaid must be notified of changes in
  provider enrollment status, including changes in
  ownership and voluntary withdrawal from
  participation in the N.C. Medicaid program.

16
Records Disposition Plan

• The plan should also designate retention periods
  and a records destruction process to take place
  when the retention period has been fulfilled and
  there is no outstanding litigation, claim, audit
  or other official action. The plan should be on
  file with the records custodian.

17
Learning Retention Exercise

• Upon viewing this presentation please notify
  Victoria Landes at [phone].