Mississippi Administrative Code
Title 23 - Division of Medicaid
Part 203 - Physician Services
Chapter 9 - Psychiatric Services
Rule 23-203-9.6 - Documentation
Universal Citation: MS Code of Rules 23-203-9.6
Current through September 24, 2024
A. Physicians are required to maintain auditable records that will verify any or all services provided and billed under the Medicaid program.
1. Records must,
be made available to representatives of the Division of Medicaid or Office of
the Attorney General in substantiation of claims.
2. Records must be maintained for a minimum
of five (5) years in order to comply with all state and federal regulations and
laws. Refer to Maintenance of Records Part 200, Chapter 1, Rule 1.3.
B. It is expected that the initial psychiatric service provided to any beneficiary must be of an evaluative nature. Documentation of the evaluation must be in the case record and must include, at a minimum:
1. Dates, including
beginning and ending session times, and the amount of time spent,
2. Chief complaint,
3. Referral source,
4. History of present illness,
5. Past psychiatric history,
6. Past medical history,
7. List of the beneficiary's current
medications including prescription, non-prescription and
over-the-counter,
8. Social and
family history,
9. Comprehensive
mental health status examination,
10. Treatment plan
formulation/prognosis,
11.
Assessment of the patient's ability to adhere to the treatment plan,
12. A multi-axial diagnosis,
13. Identification of the clinical problems
that are to be the focus of treatment,
14. Treatment modalities and/or strategies
that will be employed or are recommended to address each problem. If
medications are prescribed, documentation must include the name of the drug,
strength and dosage. The method of administration must be included for
injectable medications. Medication prescriptions must be identified as issued
in writing, electronically, or by telephone, and
15. The signature of the person who provided
and documented the service. Any note that is "signed" by computer must be
initialed by hand.
C. A treatment plan must be developed and implemented for each beneficiary no later than the date of the third (3rd) therapy session.
1. The treatment plan must include, at a
minimum:
a) A multi-axial diagnosis,
b) Identification of the
beneficiaries' and/or family's strengths,
c) Identification of the clinical problems,
or areas of need, that is to be the focus of treatment,
d) Treatment goals for each identified
problem,
e) Treatment objectives
that represent incremental progress towards goals, coupled with target dates
for their achievement,
f) Specific
treatment modalities and/or strategies that will be employed to reach each
objective, and
g) Date of
implementation and signatures of the provider and the beneficiary or
parent/legal guardian.
2. Treatment plans must be kept in the case
record and must be reviewed and revised as needed, or at least every three (3)
months. Each review must be verified by the dated signatures of the provider
and beneficiary/parent/legal guardian. The physician, nurse practitioner,
psychologist, and clinical social worker must sign the treatment plan for the
services each will provide to the beneficiary.
D. A clinical note for each therapeutic service provided must be in the case record and must:
1. Include the date of service, type of
service provided, the length of time spent delivering the service, who received
or participated in it, as well as a brief summary of what transpired. If
medications are prescribed, documentation must include the name of the drug,
strength and dosage. The method of administration must be included for
injectable medications. Medication prescriptions must be identified as issued
in writing, electronically, or by telephone.
2. Indicate whether Evaluation and Management
services are provided.
3. Relate to
the problems identified in clinical record.
4. Identify whether the service occurs in an
inpatient or outpatient setting.
5.
Be authenticated by the signature of the person who provided and documented the
service. Any note that is "signed" by computer must be initialed by
hand.
Miss. Code Ann. § 43-13-121
Disclaimer: These regulations may not be the most recent version. Mississippi may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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