Minn. R. agency 196, ch. 9505, SURVEILLANCE AND INTEGRITY REVIEW PROGRAM, pt. 9505.2175

Current through Register Vol. 49, No. 24, December 9, 2024

Part 9505.2175 - HEALTH SERVICE RECORDS

Subpart 1.Documentation requirement.

As a condition for payment by a program, a vendor must document each occurrence of a health service provided to a recipient. The health service must be documented in the recipient's health service record as specified in subpart 2 and, when applicable, subparts 3 to 9. Program funds paid for a health service not documented in a recipient's health service record shall be recovered by the department.

Subp. 2.Required standards for health service records.

A vendor must keep a health service record as specified in items A to I.

A. The record must be legible at a minimum to the individual providing care.

B. The recipient's name must be on each page of the recipient's record.

C. Each entry in the health service record must contain:

(1) the date on which the entry is made;

(2) the date or dates on which the health service is provided;

(3) the length of time spent with the recipient if the amount paid for the service depends on time spent;

(4) the signature and title of the person from whom the recipient received the service; and

(5) when applicable, the countersignature of the vendor or supervisor as required under parts 9505.0170 to 9505.0475.

D. The record must state:

(1) the recipient's case history and health condition as determined by the vendor's examination or assessment;

(2) the results of all diagnostic tests and examinations; and

(3) the diagnosis resulting from the examination.

E. The record must show the quantity, dosage, and name of prescribed drugs ordered for or administered to the recipient.

F. The record must contain reports of consultations that are ordered for the recipient.

G. The record must contain the recipient's plan of care, individual service plan as required by Minnesota Statutes, section 256B.092, or individual treatment plan. For purposes of this item, "plan of care" has the meaning given in part 9505.0175, subpart 35; and "individual treatment plan" has the meaning given in part 9505.0370, subpart 15.

H. The record must report the recipient's progress or response to treatment, and changes in the treatment or diagnosis.

I. The record of a laboratory or x-ray service must document the vendor's order for service.

Subp. 3.Requirements for pharmacy service records.

A pharmacy service record must comply with the requirements of subparts 1 and 2 and Minnesota Rules, part 6800.3110, relating to pharmacy licensing and operations, and Minnesota Rules, part 6800.3950, relating to electronic data processing of pharmacy records. However, the pharmacy service record must be a hard copy made at the time of the request for service and must be kept for five years as required under part 9505.2190, subpart 1.

Subp. 4.Medical transportation service records.

A medical transportation record must meet the requirements of subparts 1 and 2 and be signed by the driver and contain the following statement: "I certify and swear that I have accurately reported in this mileage log the miles I actually drove and the dates and times I actually drove them. I understand that misreporting the miles driven and hours worked is fraud for which I could face criminal prosecution or civil proceedings." Each transportation record for each trip must document:

A. the description and address of both the origin and destination, and the mileage for the most direct route from the origin to the destination;

B. the type of transportation provided;

C. if applicable, a physician's certification for nonemergency, ancillary, or special transportation services as defined in part 9505.0315, subpart 1, items A and F;

D. the name of the driver and license number of the vehicle used to transport the recipient;

E. whether the recipient is ambulatory or nonambulatory;

F. the time of the pick up and the time of the drop off with a.m. and p.m. designations;

G. the number of occupants in the vehicle; and

H. the name of the extra attendant when an extra attendant is used to provide special transportation services.

Subp. 5.Durable medical equipment records.

A durable medical equipment record must meet the requirements of subparts 1 and 2 and must document:

A. the type of equipment, including the brand and model names, the model number, and serial number, if available;

B. whether the equipment is being rented or purchased by the recipient;

C. when equipment is sold to a recipient, whether the equipment is under warranty and the length of the warranty;

D. repairs made by the current durable medical equipment provider to the equipment;

E. a shipping invoice or a shipping invoice with a delivery service manifest showing the date of delivery that proves that the medical equipment was delivered to the recipient; and

F. a physician's order or licensed practitioner's order for the equipment that specifies the type of equipment and the expected length of time the equipment will be needed by the recipient.

Subp. 5a.Medical supply record.

A medical supply record must meet the requirements of subparts 1 and 2 and must document:

A. a physician's order or licensed practitioner's order for the supplies that indicates the type of supply needed, the expected length of time the supplies will be needed, and the quantity needed;

B. the type and brand name of the supplies delivered to the recipient;

C. the quantity of each supply delivered to the recipient; and

D. a shipping invoice or a shipping invoice with a delivery service tracking log showing the date of delivery that proves the medical supply was delivered to the recipient.

Subp. 6.Rehabilitative and therapeutic services records.

Rehabilitative and therapeutic service records must meet the requirements of subparts 1 and 2, must meet the criteria in part 9505.0412, and must document:

A. objective and measurable goals that relate to the recipient's functioning;

B. the need for the level of service;

C. the reason the skills of a professional physical therapist or occupational therapist are needed; and

D. a licensed practitioner's order for the rehabilitative and therapeutic services.

Subp. 7. [Repealed, 48 SR 486]

Subp. 8.School-based service records.

A health service record for a child with an individualized education program who receives covered school-based services, special transportation, or assistive technology devices must meet the requirements of subparts 1 and 2 and must include the following information:

A. the medical diagnosis or condition that indicates the need for an individualized education program (IEP);

B. a current, complete copy of the recipient's IEP, individualized family service plan, or individual interagency intervention plan that documents the type, frequency, duration, and scope of the covered IEP services to be provided and measurable outcomes;

C. a copy of the recipient's release of information to bill a Minnesota health care program for IEP services signed by the recipient's parent or legal representative, or a copy of the notice provided by the district to the parent or legal representative under Minnesota Statutes, section 125A.21, subdivision 2, paragraph (b);

D. the name of the school district that provided the service and the recipient's date of birth;

E. for IEP assistive technology devices, a description of the device, including type of device, manufacturer, model, and quantity of devices, and a copy of the invoice or rental agreement; and

F. for IEP special transportation services:

(1) mileage for the most direct route from the place where the recipient is picked up and transported to the school setting where IEP covered services are provided to the recipient;

(2) type of service provided and service code;

(3) name, title, and signature of a person who can verify that the recipient received IEP special transportation on the dates specified; and

(4) documentation that the recipient received another MHCP-covered IEP service on the date for which the special transportation is billed.

Subp. 9.Language interpreter services.

A language interpreter service record must meet the requirements of subparts 1 and 2 and must document:

A. the name of the interpreter;

B. the name of the company that employed the interpreter;

C. the relationship of the interpreter to the recipient;

D. the languages spoken by the recipient and a statement that the recipient has limited English language proficiency;

E. a statement that the billed interpreter services were provided directly to the recipient while the recipient received a medically necessary covered health service; and

F. the length of time in hours and minutes that the language interpreter spent with the recipient during the direct person-to-person covered health service.

Minn. R. agency 196, ch. 9505, SURVEILLANCE AND INTEGRITY REVIEW PROGRAM, pt. 9505.2175

15 SR 2563; 19 SR 1898; 33 SR 127; 35 SR 1967; L 2011 1Sp11 art 3 s 12

48 SR 486

Statutory Authority: MS s 245.484; 256B.04; 256D.03