P.R. Laws tit. 26, § 9090
(a) Verification of charges shall include the investigation of whether or not:
(1) Charges are reported on the bill accurately;
(2) services are documented in medical or other records as having been rendered to the patient, and
(3) Services were delivered in compliance with the physician’s plan of treatment. In appropriate situations, professional staff may provide supplies or follow procedures that are in accordance with established institutional policies, procedures, or professional licensure standards. Many procedures include items that are not specifically documented in a clinical record but are referenced in medical or clinical policies. Such policies shall be reviewed, approved, and documented as required by the Joint Commission on Accreditation of Healthcare Organizations or other accreditation agencies. Policies shall be available for review by the auditor.
(b) The clinical record documents clinical data on diagnoses, treatments and results. It is not designed to be a billing document. A patient’s clinical record generally documents pertinent information related to care and may not back up each individual charge on the patient bill. Other signed documentation for services provided to the patient may exist within the provider’s ancillary departments in the form of department treatment logs, daily records, individual service or order tickets, and other documents.
(c) Auditors may review a number of other documents to determine valid charges. Auditors must recognize that these sources of information are accepted as reasonable evidence that the services ordered by the physician were actually provided to the patient. Providers must ensure that proper policies and procedures exist to specify what documentation and authorizations must be in the clinical record and in ancillary records and logs. These procedures must also document that services have been properly ordered for and delivered to patients. When sources other than the clinical record are furnishing documentation, the provider shall notify the auditor and make those sources available to him/her.
History —Aug. 29, 2011, No. 194, § 6.100, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 12 eff. 30 days after July 10, 2013.