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Minnesota Administrative Rules

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.

Personal care provider service records.

Health care service records maintained by a personal care provider, consumer-directed home care provider, or fiscal agent must meet the requirements of subparts 1 and 2 and must document:

A.

a physician's initial order for personal care services in the form required by the commissioner, which shall be included prior to, or within 30 days after the start of such services, and documentation that the physician's order has been reviewed by the physician at least once every 365 days;

B.

the care plan completed by the supervising qualified professional which details the qualified professional's instruction to the personal care assistant;

C.

the department's notice of prior authorization which identifies the amount of personal care service and qualified professional supervision authorized for the recipient;

D.

whether the recipient is in a shared care arrangement, and if so, the record must also meet the documentation requirements of Minnesota Statutes, section 256B.0655, subdivision 5, paragraph (g);

E.

whether the recipient is using the flexible services use option authorized by Minnesota Statutes, section 256B.0655, subdivision 6;

F.

whether the recipient is using a fiscal agent and if so, the name of the agent;

G.

whether the recipient is using a consumer-directed service delivery alternative;

H.

for all care arrangements, the following documentation must be made for each day that care is provided by each personal care assistant who provides care to the recipient:

(1)

the recipient's name;

(2)

the name of the personal care assistant providing services;

(3)

the day, month, and year the personal care services were provided;

(4)

the total number of hours spent providing personal care services to the recipient;

(5)

the time of arrival at the site where personal care services were provided and the time of departure from the site where services were provided, including a.m. and p.m. designations;

(6)

the personal care services provided;

(7)

notes by the personal care assistant regarding changes in the recipient's condition, documentation of calls to the supervising qualified professional, and other notes as required by the supervising qualified professional;

(8)

the personal care assistant's signature on the time sheets which record the hours worked by the personal care assistant, and must contain the following statement: "I certify and swear that I have accurately reported on this time sheet the hours I actually worked, the services I provided, and the dates and times worked. I understand that misreporting my hours is fraud for which I could face criminal prosecution and civil proceedings"; and

(9)

the recipient's signature, stamp, or mark, or the responsible party's signature, if the recipient requires a responsible party;

I.

in a shared care arrangement, the following additional requirements apply:

(1)

each personal care assistant must satisfy the daily documentation requirements in item H and the documentation requirements of Minnesota Statutes, section 256B.0655, subdivision 5, paragraph (g), for each recipient;

(2)

the qualified professional must document supervision of shared care services including:

(a)

ongoing monitoring and evaluation of the effectiveness and appropriateness of shared care;

(b)

the date, time of day, and number of hours spent supervising the provision of shared services;

(c)

whether the supervision was face-to-face or another method of supervision;

(d)

changes in the recipient's condition;

(e)

scheduling issues; and

(f)

recommendations;

(3)

the qualified professional must document consent by the recipient or the recipient's responsible party, if any, for shared care; and

(4)

the qualified professional must document revocation by the recipient or the recipient's responsible party, if any, of the shared care option;

J.

authorization by the recipient's responsible party, if any, for personal care services provided outside the recipient's residence;

K.

authorization by the responsible party, who is a parent of a minor recipient or a guardian of a recipient, which is approved and signed by the supervising nurse, to delegate to another adult the responsible party function for absences of at least 24 hours but not more than six days; and

L.

supervision by the supervising qualified professional, including the date of the provision of supervision of personal care services as specified in part 9505.0335, subpart 4.

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.

Statutory Authority:

MS s 245.484; 256B.04; 256D.03

History:

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

Published Electronically:

February 18, 2013

700 State Office Building, 100 Rev. Dr. Martin Luther King Jr. Blvd., St. Paul, MN 55155 ♦ Phone: (651) 296-2868 ♦ TTY: 1-800-627-3529 ♦ Fax: (651) 296-0569