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 provider’s 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 (919)855-4389.