Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 423.000 - Freestanding Ambulatory Surgical Centers
Section 423.413 - Recordkeeping Requirements
Current through Register 1531, September 27, 2024
Surgical centers must maintain a medical-record system promoting quality and confidential patient care in accordance with 105 CMR 140.000: Licensure of Clinics. This system must collect and retain data in a comprehensive and efficient manner and permit the prompt retrieval of information. Accurate and complete medical records must be maintained for each member receiving surgical services from the surgical center. The data maintained in the member's medical record must also be sufficient to justify any further diagnostic procedures, treatments, recommendations for return visits, and referrals. The medical record must be clear and legible, and readily accessible to health care practitioners and the MassHealth agency. The medical record must be maintained by the surgical center for six years.
(A) Documentation. Payment for any service covered by MassHealth is conditioned upon its full and complete documentation in the member's medical record. Payment for maintaining the member's medical record is included in the fee for the facility component. Each medical record must contain sufficient information to fully document the nature, extent, quality, and necessity of the care furnished to the member for each date of service claimed for payment. If the information in the member's record is not sufficient to document the service for which payment is claimed by the provider, the MassHealth agency will not pay for the service or, if payment has been made, may consider such payment to be an overpayment subject to recovery as defined in the MassHealth administrative and billing regulations in 130 CMR 450.000: Administrative and Billing Regulations. The medical record requirements in 130 CMR 423.000 constitute the standard against which the adequacy of records will be measured, as set forth in 130 CMR 450.000: Administrative and Billing Regulations.
(B) Components. The medical record must include the following:
(C) Clinical Laboratory and Radiology Services. For clinical laboratory services and radiologic services, additional information must be maintained in the member's medical record in relation to the payable surgical procedure, as well as a record of each specimen and laboratory test result for at least six years from the date on which the results were reported to the prescriber. This record must include the following components:
(D) Pharmacy Services. Surgical center pharmacies must maintain, for six years, a record for each member of the drug and amount dispensed, the date, and the original prescription. Verbal orders for the administration of all drugs and biologicals must be followed by a written order signed by the prescriber at the completion of the surgical procedure.