Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 432.000 - Therapist Services
Section 432.418 - Recordkeeping Requirements

Universal Citation: 130 MA Code of Regs 130.432

Current through Register 1531, September 27, 2024

Payment for any service listed in 130 CMR 432.000 is conditioned upon its full and complete documentation by the provider in the member's medical record. Records must be retained by the provider in accordance with 130 CMR 450.205(G) and any other guidance provided by the MassHealth agency. The therapist is responsible for the complete documentation of therapy services provided, including therapy services provided under the therapist's supervision. The record must include the following:

(A) the prescribing provider's initial written prescription, and, if applicable, prescription renewals every 60 days (see 130 CMR 432.415);

(B) the written initial evaluation report and, if applicable, any subsequent reevaluation (see 130 CMR 432.416);

(C) the name, NPI, and telephone number of the member's prescribing provider;

(D) the written documentation for each date on which therapy was provided, including the following:

(1) the date on which therapy was provided;

(2) the amount of time spent in therapy;

(3) the specific therapeutic procedures and methods used;

(4) the teaching tools provided to the member, their family, or other persons;

(5) the member's response to treatment;

(6) any changes in the member's condition;

(7) the problems encountered or changes in the plan of care or goals, if any;

(8) the location where the service was provided, if different from that in the evaluation or reevaluation report;

(9) the therapist's signature and, if applicable, the signature of the licensed physical therapy assistant, the licensed occupational therapy assistant, or licensed speech/language therapy assistant; and

(10) written documentation demonstrating measurable, objective, and functional progress as a direct result of treatment, excluding those who meet criteria in 130 CMR 432.414(D).

(E) as applicable, a copy of the prior authorization request(s), including a copy of any prior authorization forms, as designated by the MassHealth agency, and the MassHealth agency's response;

(F) documentation on the teaching provided to the member, member's family, or caregiver by the therapist on how to manage the member's treatment regimen, any ongoing teaching required due to a change in the treatment or the member's condition, and the response to the teaching; or as applicable, documentation indicating that teaching was unsuccessful or unnecessary and why further teaching is not reasonable.

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