Mississippi Administrative Code
Title 23 - Division of Medicaid
Part 213 - Therapy Services
Chapter 2 - Occupational Therapy
Rule 23-213-2.9 - Documentation
Universal Citation: MS Code of Rules 23-213-2.9
Current through September 24, 2024
A. Occupational therapy providers must document and maintain records in accordance with the requirements set forth in Part 200, Chapter 1, Rule 1.3.
B. Required documentation by an occupational therapy servicing provider includes, but is not limited to, the following:
1. Beneficiary demographic information,
2. A copy of the Certificate of
Medical Necessity for Initial Referral/Orders completed by the prescribing
provider,
3. Signed consent for
treatment,
4. Original copies of
all Outpatient Therapy Evaluation/Re-Evaluation forms specific to the therapy
ordered,
5. Original copies of all
Outpatient Therapy Plan of Care forms specific to the therapy ordered,
6. Original copies of all tests
performed or a list of all tests performed, test results, and the written
evaluation reports,
7. Treatment
log if treatment times are not documented in the progress notes including all
requirements of timed codes as follows:
a)
The Division of Medicaid defines timed codes as procedure codes that reference
a time per unit.
b) The Division
of Medicaid covers units of timed codes based upon the total time actually
spent in the delivery of the service.
c) The Division of Medicaid considers the
following activities as not part of the total treatment time:
1) Pre and post-delivery of services,
2) Time the beneficiary spends not
being treated, and
3) Time waiting
for equipment or for treatment to begin.
d) The Division of Medicaid defines untimed
codes as procedure codes that are not defined by a specific time frame.
e) The Division of Medicaid does
not require documentation of the treatment time for untimed codes.
f) The Division of Medicaid only covers one
(1) unit for untimed codes regardless of the amount of time taken to complete
the service.
8.
Progress notes:
a) Must be documented at
least weekly.
b) Must include:
1) Date/time of service,
2) Specific treatment modalities/procedures
performed,
3) Beneficiary's
response to treatment, functional progress,
4) Problems interfering with progress,
5) Education/teaching activities
and results,
6) Conferences,
7) Progress toward discharge
goals/home program activities, and
8) The signature and title of the therapist
providing the service(s).
c) If treatment times are documented in the
progress notes in lieu of a treatment log, all requirements for timed codes
must be met, Refer to timed and untimed codes in this Part.
9. Discharge Summary, if
applicable, and
10. A copy of the
completed prior approval form with prior approval authorization, if applicable.
C. Required documentation by a prescribing occupational therapy provider includes, but is not limited to, the following:
1. Date(s) of
service,
2. Beneficiary
demographic information,
3. Signed
consent for treatment,
4. Medical
history/chief complaint,
5.
Diagnosis,
6. Specific name/type
of all diagnostic studies and results/findings of the studies,
7. Treatment rendered and response to
treatment,
8. Medications
prescribed including name, strength, dosage, and route,
9. Orders that are signed and dated for all
medications, treatments, and procedures rendered,
10. Discharge planning and beneficiary
instructions,
11. Copy of the
Certificate of Medical Necessity for Initial Referral/Orders, and
12. Evidence that the beneficiary was seen,
face-to-face, and evaluated/re-evaluated every six (6) months, at a minimum.
D. The prescribing occupational therapy provider must retain copies of the rendering provider's/ therapist's documentation as follows:
1.
Initial therapy evaluation and all re-evaluations,
2. Initial plan of care and all revisions,
3. Written evaluation reports for
all tests, and
4. Discharge
summary, if applicable.
42 C.F.R. §§ 422.504, 485.715; Miss. Code Ann. §§ 43-13-117, 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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