Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 434.000 - Psychiatric Hospital Outpatient Services › Section 434.410 - Recordkeeping (Medical Records) Requirements

Current through Register 1525, July 5, 2024
(A) Payment for any psychiatric hospital
			 outpatient service reimbursable under MassHealth is conditioned upon its full
			 and complete documentation in the member's medical record. If the information
			 in the member's record is not sufficient to document the service for which
			 payment is claimed by the provider, the MassHealth agency will not pay for the
			 service or, if payment has been made, will consider such payment to be an
			 overpayment subject to recovery as defined in the MassHealth administrative and
			 billing regulations in
			 130 CMR 450.000. Medical
			 record requirements as set forth in
			 130 CMR 434.000 constitute
			 the standard against which the adequacy of records will be measured, as set
			 forth in
			 130 CMR 450.000.
(B) The MassHealth agency may request, and
			 the psychiatric inpatient hospital must furnish, any and all medical records
			 (or clear photocopies of such records) corresponding to or documenting the
			 services claimed, in accordance with M.G.L. c. 118E, § 38, and
			 130 CMR 450.000. All
			 components of a member's complete medical record (such as lab slips and X rays)
			 need not be maintained in one file as long as all components are accessible to
			 the MassHealth agency upon its request.
(C) The medical record must contain
			 sufficient data to document fully the nature, extent, quality, and necessity of
			 the care furnished to a member for each date of service claimed for payment, as
			 well as any data that will update the member's medical course. The data
			 maintained in the member's medical record must also be sufficient to justify
			 any further diagnostic procedures, treatments, recommendations for return
			 visits, and referrals.
(D) The
			 medical records for hospital outpatient services provided to members must
			 include at least the following information (basic data collected during
			 previous visits, such as identifying data, chief complaint, or history, need
			 not be repeated in the member's medical record for subsequent visits):
(1) the member's name and date of
			 birth;
(2) the date of each
			 service;
(3) the reason for the
			 visit;
(4) the name and title of
			 the person who performed the service;
(5) the member's medical history;
(6) the diagnosis or chief
			 complaint;
(7) a clear indication
			 of all findings, whether positive or negative, on examination;
(8) any tests administered and their
			 results;
(9) a description of any
			 treatment given;
(10) any
			 medications administered or prescribed, including strength, dosage, regimen,
			 and duration of use;
(11) any
			 anesthetic agent administered;
(12)
			 any medical goods or supplies dispensed or supplied;
(13) recommendations and referrals for
			 additional treatments or consultations, when applicable;
(14) such other information as is applicable
			 for the specific service provided, or as is otherwise required in
			 130 CMR 434.000;
			 and
(15) for members under the age
			 of 21, the CANS that was completed at the initial behavioral-health assessment
			 and updated at least every 90 days thereafter.