Section 405 IAC 5-21.8-6 - Clinical documentation requirementsAuthority: IC 12-8-6.5-5; IC 12-15
Affected: IC 12-7-2-40.6; IC 12-13-7-3; IC 12-15-2-3.5; IC 12-29-2; IC 25-23-1-1; IC 25-23.6-10.5; IC 25-27.5-5
Sec. 6.
(a) To be reimbursable under this rule, the BPHC service must be supported by clinical documentation that is maintained in the member's clinical record.(b) The documentation required to support billing for BPHC services must meet the following standards: (1) Reflect progress toward the goals reflected in the member's IICP.(2) Be updated with every member encounter when billing is submitted for reimbursement.(3) Be written and signed by the agency staff rendering services.(c) The documentation to support billing for BPHC services should:(1) focus on recovery and habilitation or rehabilitation;(2) support coordination or management of identified health needs and services; and(3) emphasize member strengths.(d) Clinical documentation of services provided under this section must contain the following information: (1) The type of service being provided.(2) The names and qualifications of the staff providing the service.(3) The location or setting where the service was provided.(4) The focus of the session or service delivered to or on behalf of the member.(5) The member's symptoms, needs, goals, or issues addressed during the session.(6) The actual time spent rendering the service.(7) The start and end time of the service.(8) The member's IICP goal being addressed during the session.(9) The progress made toward meeting goals noted on the IICP.(10) The date of service rendered including month, day, and year.(e) The content of the documentation must support the amount of time billed.(f) For BPHC services provided on behalf of the member without the member present, documentation must be provided for each encounter and must include the following information: (1) The names of all persons attending the session and each person's relationship to the member.(2) How the service: (A) benefits the member; and(B) assists the member in reaching the IICP goals.(g) A provider shall maintain documentation for services provided to a BPHC services member in accordance with the requirements under 405 IAC 1-5-1. Office of the Secretary of Family and Social Services; 405 IAC 5-21.8-6; filed Apr 8, 2014, 12:41 p.m.: 20140507-IR-405130530FRAFiled 8/1/2016, 3:44 p.m.: 20160831-IR-405150418FRAReadopted filed 7/28/2022, 2:21 p.m.: 20220824-IR-405220205RFAReadopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA