Section 441.79.3. Maintenance of records by providers of service.

A provider of a service that is charged to the medical assistance program shall maintain complete and legible records as required in this rule. Failure to maintain records or failure to make records available to the department or to its authorized representative timely upon request shall result in claim denial or recoupment.

         79.3(1) Financial (fiscal) records.

            a.               A provider of service shall maintain records as necessary to:

             (1)             Support the determination of the provider’s reimbursement rate under the medical assistance program; and

             (2)             Support each item of service for which a charge is made to the medical assistance program. These records include financial records and other records as may be necessary for reporting and accountability.

            b.               A financial record does not constitute a medical record.

         79.3(2) Medical (clinical) records. A provider of service shall maintain complete and legible medical records for each service for which a charge is made to the medical assistance program. Required records shall include any records required to maintain the provider’s license in good standing.

            a.                Definition. “Medical record” (also called “clinical record”) means a tangible history that provides evidence of:

             (1)             The provision of each service and each activity billed to the program; and

             (2)             First and last name of the member receiving the service.

            b.                Purpose. The medical record shall provide evidence that the service provided is:

             (1)             Medically necessary;

             (2)             Consistent with the diagnosis of the member’s condition; and

             (3)             Consistent with professionally recognized standards of care.

            c.                Components.

             (1)             Identification. Each page or separate electronic document of the medical record shall contain the member’s first and last name. In the case of electronic documents, the member’s first and last name must appear on each screen when viewed electronically and on each page when printed. As part of the medical record, the medical assistance identification number and the date of birth must also be identified and associated with the member’s first and last name.

             (2)             Basis for service—general rule. General requirements for all services are listed herein. For the application of these requirements to specific services, see paragraph 79.3(2)“d.” The medical record shall reflect the reason for performing the service or activity, substantiate medical necessity, and demonstrate the level of care associated with the service. The medical record shall include the items specified below unless the listed item is not routinely received or created in connection with a particular service or activity and is not required to document the reason for performing the service or activity, the medical necessity of the service or activity, or the level of care associated with the service or activity:

            1.      The member’s complaint, symptoms, and diagnosis.

            2.      The member’s medical or social history.

            3.      Examination findings.

            4.      Diagnostic test reports, laboratory test results, or X-ray reports.

            5.      Goals or needs identified in the member’s plan of care.

            6.      Physician orders and any prior authorizations required for Medicaid payment.

            7.      Medication records, pharmacy records for prescriptions, or providers’ orders.

            8.      Related professional consultation reports.

            9.      Progress or status notes for the services or activities provided.

            10.     All forms required by the department as a condition of payment for the services provided.

            11.     Any treatment plan, care plan, service plan, individual health plan, behavioral intervention plan, or individualized education program.

            12.     The provider’s assessment, clinical impression, diagnosis, or narrative, including the complete date thereof and the identity of the person performing the assessment, clinical impression, diagnosis, or narrative.

            13.     Any additional documentation necessary to demonstrate the medical necessity of the service provided or otherwise required for Medicaid payment.

             (3)             Service documentation. The record for each service provided shall include information necessary to substantiate that the service was provided and shall include the following:

            1.      The specific procedures or treatments performed.

            2.      The complete date of the service, including the beginning and ending date if the service is rendered over more than one day.

            3.      The complete time of the service, including the beginning and ending time if the service is billed on a time-related basis. For those non-time-related services billed using Current Procedural Terminology (CPT) codes, the total time of the service shall be recorded, rather than the beginning and ending time.

            4.      The location where the service was provided if otherwise required on the billing form or in 441—paragraph 77.30(5)“c” or “d,” 441—paragraph 77.33(6)“d,” 441—paragraph 77.34(5)“d,” 441—paragraph 77.37(15)“d,” 441—paragraph 77.39(13)“e,” 441—paragraph 77.39(14)“d,” or 441—paragraph 77.46(5)“i,” or 441—subparagraph 78.9(10)“a”(1).

            5.      The name, dosage, and route of administration of any medication dispensed or administered as part of the service.

            6.      Any supplies dispensed as part of the service.

            7.      The first and last name and professional credentials, if any, of the person providing the service.

            8.      The signature of the person providing the service, or the initials of the person providing the service if a signature log indicates the person’s identity.

            9.      For 24-hour care, documentation for every shift of the services provided, the member’s response to the services provided, and the person who provided the services.

             (4)             Outcome of service. The medical record shall indicate the member’s progress in response to the services rendered, including any changes in treatment, alteration of the plan of care, or revision of the diagnosis.

            d.                Basis for service requirements for specific services. The medical record for the following services must include, but is not limited to, the items specified below (unless the listed item is not routinely received or created in connection with the particular service or activity and is not required to document the reason for performing the service or activity, its medical necessity, or the level of care associated with it). These items will be specified on Form 470-4479, Documentation Checklist, when the Iowa Medicaid enterprise program integrity unit requests providers to submit records for review. (See paragraph 79.4(2)“b.”)

             (1)             Physician (MD and DO) services:

            1.      Service or office notes or narratives.

            2.      Procedure, laboratory, or test orders and results.

             (2)             Pharmacy services:

            1.      Prescriptions.

            2.      Nursing facility physician order.

            3.      Telephone order.

            4.      Pharmacy notes.

            5.      Prior authorization documentation.

             (3)             Dentist services:

            1.      Treatment notes.

            2.      Anesthesia notes and records.

            3.      Prescriptions.

             (4)             Podiatrist services:

            1.      Service or office notes or narratives.

            2.      Certifying physician statement.

            3.      Prescription or order form.

             (5)             Certified registered nurse anesthetist services:

            1.      Service notes or narratives.

            2.      Preanesthesia physical examination report.

            3.      Operative report.

            4.      Anesthesia record.

            5.      Prescriptions.

             (6)             Other advanced registered nurse practitioner services:

            1.      Service or office notes or narratives.

            2.      Procedure, laboratory, or test orders and results.

             (7)             Optometrist and optician services:

            1.      Notes or narratives supporting eye examinations, medical services, and auxiliary procedures.

            2.      Original prescription or updated prescriptions for corrective lenses or contact lenses.

            3.      Prior authorization documentation.

             (8)             Psychologist services:

            1.      Service or office psychotherapy notes or narratives.

            2.      Psychological examination report and notes.

             (9)             Clinic services:

            1.      Service or office notes or narratives.

            2.      Procedure, laboratory, or test orders and results.

            3.      Nurses’ notes.

            4.      Prescriptions.

            5.      Medication administration records.

             (10)            Services provided by rural health clinics or federally qualified health centers:

            1.      Service or office notes or narratives.

            2.      Form 470-2942, Prenatal Risk Assessment.

            3.      Procedure, laboratory, or test orders and results.

            4.      Immunization records.

             (11)            Services provided by community mental health centers:

            1.      Service referral documentation.

            2.      Initial evaluation.

            3.      Individual treatment plan.

            4.      Service or office notes or narratives.

            5.      Narratives related to the peer review process and peer review activities related to a member’s treatment.

            6.      Written plan for accessing emergency services.

             (12)            Screening center services:

            1.      Service or office notes or narratives.

            2.      Immunization records.

            3.      Laboratory reports.

            4.      Results of health, vision, or hearing screenings.

             (13)            Family planning services:

            1.      Service or office notes or narratives.

            2.      Procedure, laboratory, or test orders and results.

            3.      Nurses’ notes.

            4.      Immunization records.

            5.      Consent forms.

            6.      Prescriptions.

            7.      Medication administration records.

             (14)            Maternal health center services:

            1.      Service or office notes or narratives.

            2.      Procedure, laboratory, or test orders and results.

            3.      Form 470-2942, Prenatal Risk Assessment.

             (15)            Birthing center services:

            1.      Service or office notes or narratives.

            2.      Form 470-2942, Prenatal Risk Assessment.

             (16)            Ambulatory surgical center services:

            1.      Service notes or narratives (history and physical, consultation, operative report, discharge summary).

            2.      Physician orders.

            3.      Consent forms.

            4.      Anesthesia records.

            5.      Pathology reports.

            6.      Laboratory and X-ray reports.

             (17)            Hospital services:

            1.      Physician orders.

            2.      Service notes or narratives (history and physical, consultation, operative report, discharge summary).

            3.      Progress or status notes.

            4.      Diagnostic procedures, including laboratory and X-ray reports.

            5.      Pathology reports.

            6.      Anesthesia records.

            7.      Medication administration records.

             (18)            State mental hospital services:

            1.      Service referral documentation.

            2.      Resident assessment and initial evaluation.

            3.      Individual comprehensive treatment plan.

            4.      Service notes or narratives (history and physical, therapy records, discharge summary).

            5.      Form 470-0042, Case Activity Report.

            6.      Medication administration records.

             (19)            Services provided by skilled nursing facilities, nursing facilities, and nursing facilities for persons with mental illness:

            1.      Physician orders.

            2.      Progress or status notes.

            3.      Service notes or narratives.

            4.      Procedure, laboratory, or test orders and results.

            5.      Nurses’ notes.

            6.      Physical therapy, occupational therapy, and speech therapy notes.

            7.      Medication administration records.

            8.      Form 470-0042, Case Activity Report.

             (20)            Services provided by intermediate care facilities for persons with mental retardation:

            1.      Physician orders.

            2.      Progress or status notes.

            3.      Preliminary evaluation.

            4.      Comprehensive functional assessment.

            5.      Individual program plan.

            6.      Form 470-0374, Resident Care Agreement.

            7.      Program documentation.

            8.      Medication administration records.

            9.      Nurses’ notes.

            10.     Form 470-0042, Case Activity Report.

             (21)            Services provided by psychiatric medical institutions for children:

            1.      Physician orders or court orders.

            2.      Independent assessment.

            3.      Individual treatment plan.

            4.      Service notes or narratives (history and physical, therapy records, discharge summary).

            5.      Form 470-0042, Case Activity Report.

            6.      Medication administration records.

             (22)            Hospice services:

            1.      Physician certifications for hospice care.

            2.      Form 470-2618, Election of Medicaid Hospice Benefit.

            3.      Form 470-2619, Revocation of Medicaid Hospice Benefit.

            4.      Plan of care.

            5.      Physician orders.

            6.      Progress or status notes.

            7.      Service notes or narratives.

            8.      Medication administration records.

            9.      Prescriptions.

             (23)            Services provided by rehabilitation agencies:

            1.      Physician orders.

            2.      Initial certification, recertifications, and treatment plans.

            3.      Narratives from treatment sessions.

            4.      Treatment and daily progress or status notes and forms.

             (24)            Home- and community-based habilitation services:

            1.      Notice of decision for service authorization.

            2.      Service plan (initial and subsequent).

            3.      Service notes or narratives.

             (25)            Behavioral health intervention:

            1.      Order for services.

            2.      Comprehensive treatment or service plan (initial and subsequent).

            3.      Service notes or narratives.

             (26)            Services provided by area education agencies and local education agencies:

            1.      Service notes or narratives.

            2.      Individualized education program (IEP).

            3.      Individual health plan (IHP).

            4.      Behavioral intervention plan.

             (27)            Home health agency services:

            1.      Plan of care or plan of treatment.

            2.      Certifications and recertifications.

            3.      Service notes or narratives.

            4.      Physician orders or medical orders.

             (28)            Services provided by independent laboratories:

            1.      Laboratory reports.

            2.      Physician order for each laboratory test.

             (29)            Ambulance services:

            1.      Documentation on the claim or run report supporting medical necessity of the transport.

            2.      Documentation supporting mileage billed.

             (30)            Services of lead investigation agencies:

            1.      Service notes or narratives.

            2.      Child’s lead level logs (including laboratory results).

            3.      Written investigation reports to family, owner of building, child’s medical provider, and local childhood lead poisoning prevention program.

            4.      Health education notes, including follow-up notes.

             (31)            Medical supplies:

            1.      Prescriptions.

            2.      Certificate of medical necessity.

            3.      Prior authorization documentation.

            4.      Medical equipment invoice or receipt.

             (32)            Orthopedic shoe dealer services:

            1.      Service notes or narratives.

            2.      Prescriptions.

            3.      Certifying physician’s statement.

             (33)            Case management services, including HCBS case management services:

            1.      Form 470-3956, MR/CMI/DD Case Management Service Authorization Request, for services authorized before May 1, 2007.

            2.      Notice of decision for service authorization.

            3.      Service notes or narratives.

            4.      Social history.

            5.      Comprehensive service plan.

            6.      Reassessment of member needs.

            7.      Incident reports in accordance with 441—subrule 24.4(5).

             (34)            Early access service coordinator services:

            1.      Individualized family service plan (IFSP).

            2.      Service notes or narratives.

             (35)            Home- and community-based waiver services, other than case management:

            1.      Notice of decision for service authorization.

            2.      Service plan.

            3.      Service logs, notes, or narratives.

            4.      Mileage and transportation logs.

            5.      Log of meal delivery.

            6.      Invoices or receipts.

            7.      Forms 470-3372, HCBS Consumer-Directed Attendant Care Agreement, and 470-4389, Consumer-Directed Attendant Care (CDAC) Service Record.

             (36)            Physical therapist services:

            1.      Physician order for physical therapy.

            2.      Initial physical therapy certification, recertifications, and treatment plans.

            3.      Treatment notes and forms.

            4.      Progress or status notes.

             (37)            Chiropractor services:

            1.      Service or office notes or narratives.

            2.      X-ray results.

             (38)            Hearing aid dealer and audiologist services:

            1.      Physician examinations and audiological testing (Form 470-0361, Sections A, B, and C).

            2.      Documentation of hearing aid evaluation and selection (Form 470-0828).

            3.      Waiver of informed consent.

            4.      Prior authorization documentation.

            5.      Service or office notes or narratives.

             (39)            Behavioral health services:

            1.      Assessment.

            2.      Individual treatment plan.

            3.      Service or office notes or narratives.

             (40)            Health home services:

            1.      Comprehensive care management plan.

            2.      Care coordination and health promotion plan.

            3.      Comprehensive transitional care plan, including appropriate follow-up, from inpatient to other settings.

            4.      Documentation of member and family support (including authorized representatives).

            5.      Documentation of referral to community and social support services, if relevant.

             (41)            Services of public health agencies:

            1.      Service or office notes or narratives.

            2.      Immunization records.

            3.      Results of communicable disease testing.

             (42)            Community-based neurobehavioral rehabilitation residential services and community-based neurobehavioral rehabilitation intermittent services:

            1.      Department-approved standardized neurobehavioral assessment tool.

            2.      Community-based neurobehavioral treatment order.

            3.      Treatment plan.

            4.      Clinical records documenting diagnosis and treatment history.

            5.      Progress or status notes.

            6.      Service notes or narratives.

            7.      Procedure, laboratory, or test orders and results.

            8.      Therapy notes including but not limited to occupational therapy, physical therapy, and speech-language pathology services as applicable.

            9.      Medication administration records.

             (43)            Child care medical services:

            1.      Plan of care.

            2.      Certification and recertification.

            3.      Service notes or narratives.

            4.      Physician orders or medical orders.

            5.      Abbreviation list (a copy of the abbreviation list utilized within the member’s record).

            6.      If initials or incomplete signatures are noted within the member’s record, a signature log (a typed listing of each provider’s name, including initials, professional credentials and title, followed by the individual provider’s signature).

            e.                Corrections. A provider may correct the medical record before submitting a claim for reimbursement.

             (1)             Corrections must be made or authorized by the person who provided the service or by a person who has first-hand knowledge of the service.

             (2)             A correction to a medical record must not be written over or otherwise obliterate the original entry. A single line may be drawn through erroneous information, keeping the original entry legible. In the case of electronic records, the original information must be retained and retrievable.

             (3)             Any correction must indicate the person making the change and any other person authorizing the change, must be dated and signed by the person making the change, and must be clearly connected with the original entry in the record.

             (4)             If a correction made after a claim has been submitted affects the accuracy or validity of the claim, an amended claim must be submitted.

         79.3(3) Maintenance requirement. The provider shall maintain records as required by this rule:

            a.               During the time the member is receiving services from the provider.

            b.               For a minimum of five years from the date when a claim for the service was submitted to the medical assistance program for payment.

            c.               As may be required by any licensing authority or accrediting body associated with determining the provider’s qualifications.

         79.3(4) Availability. Rescinded IAB 1/30/08, effective 4/1/08.

This rule is intended to implement Iowa Code section 249A.4.

[ARC 7957B, IAB 7/15/09, effective 7/1/09; ARC 8262B, IAB 11/4/09, effective 12/9/09; ARC 9440B, IAB 4/6/11, effective 4/1/11; ARC 9487B, IAB 5/4/11, effective 7/1/11; ARC 0198C, IAB 7/11/12, effective 7/1/12; ARC 0358C, IAB 10/3/12, effective 11/7/12; ARC 0711C, IAB 5/1/13, effective 7/1/13; ARC 1695C, IAB 10/29/14, effective 1/1/15; ARC 2361C, IAB 1/6/16, effective 1/1/16; ARC 2341C, IAB 1/6/16, effective 2/10/16]