23 Miss. Code. R. 215-1.6

Current through October 10, 2024

Rule 23-215-1.6 - Documentation

A. The Division of Medicaid requires the home health agency to maintain auditable records that substantiate the services provided and include, at a minimum, the following in each beneficiary's record verifying services provided by the home health agency are medically necessary [Refer to Maintenance of Records Part 200, Rule 1.3.]:

1. Physician or non-physician practitioner (NPP) referral,

2. Appropriate information identifying the beneficiary,

3. Name of the physician or NPP,

4. Documentation of the face-to-face encounter with the ordering physician or allowed nonphysician practitioner (NPP) including:

a) Documentation that the required face-to-face encounter related to the primary reason the beneficiary needs the services occurred ninety (90) days before or thirty (30) days after the start of home health services,

b) Identification of the physician or allowed NPP who conducted the encounter, and

c) The date of the face-to-face encounter,

5. If the face-to-face encounter was performed by an allowed NPP, the clinical findings of the face-to-face encounter must be incorporated into a written or electronic document in the beneficiary's medical record.

6. Documentation that the services cannot be provided in any other setting other than the beneficiary's residence.

7. The initial order and all recertifications signed by the physician or NPP which must include:

a) Justification home health services are medically necessary and reasonable for treatment of the beneficiary's illness, injury, or condition,

b) The type of services required, and

c) The estimated duration home health services will be needed,

8. The beneficiary's plan of care,

9. Documentation that the beneficiary's plan of care is reviewed and recertified by a physician or NPP every sixty (60) days,

10. Signed copy of orders, new orders or changes in orders for medications, medical supplies, treatments, dietary, and activities,

11. Case conference report(s) covering all disciplines,

12. Lab results and other diagnostic test results,

13. Discharge summary to include transfers and hospital stays,

14. Documentation of all verbal communications between the home health agency and the physician and/or allowed NPP, and

15. Documentation that a supervisory visit was made by a registered nurse (RN) at least every sixty (60) days for home health aide services.

B. Home health agencies must provide and the physician must maintain copies of the documentation in Miss. Admin. Code Part 215, Rule 1.6.A. in each beneficiary's record verifying services provided by the home health agency are medically necessary. [Refer to Maintenance of Records Part 200, Rule 1.3.]

23 Miss. Code. R. 215-1.6

42 C.F.R. §§ 440.70, 484.48; Miss. Code Ann. §§ 43-13-117, 43-13-118, 43-13-121, 4313-129.

Amended 9/1/2018

Amended 7/1/2021