Current through Register Vol. 56, No. 18, September 16, 2024
(a) The APN, in any and all settings, shall keep such legible individual written records and/or electronic medical records (EMR) as are necessary to fully disclose the kind and extent of service(s) provided, the procedure code being billed and the medical necessity for those services.
(b) Documentation of services performed by the APN shall include, as a minimum:
1. The date of service;
2. The name of the beneficiary;
3. The beneficiary's chief complaint(s), reason for visit;
4. Review of systems;
5. Physical examination;
6. Diagnosis;
7. A plan of care, including diagnostic testing and treatment(s);
8. The signature of the APN rendering the service; and
9. Other documentation appropriate to the procedure code being billed. (See N.J.A.C. 10:58A-4, HCPCS Codes.)
(c) In order to receive reimbursement for an initial visit, the following documentation, at a minimum, shall be placed on the medical record by the APN, regardless of the setting where the examination was performed:
1. Chief complaint(s);
2. A complete history of the present illness, with current medications and review of systems, including recordings of pertinent negative findings;
3. Pertinent medical history;
4. Pertinent family and social history;
5. A complete physical examination;
6. Diagnosis; and
7. Plan of care, including diagnostic testing and treatment.
(d) Written and/or electronic medical records in substantiation of the use of a given procedure code shall be available for review and/or inspection if requested by the New Jersey Medicaid/NJ FamilyCare fee-for-service program.
(e) Further discussion of the extent of documentation requirements can be found at 10:49-9.7, 9.8 and 9.9.
(f) Records, and the documentation of visits to beneficiaries in residential health care facilities, shall be maintained in the provider's office record. Residential health care facility records, as specified in (c) above, shall be part of the office records.
(g) In order to document the record for reimbursement purposes, the progress note for routine office visits or follow up care visits shall include the following:
1. In an office or residential health care facility:
i. The beneficiary's chief complaint(s), reason for visit;
ii. Pertinent medical, family and social history obtained;
iii. Pertinent physical findings, including pertinent negative physical findings based on (g)1i and ii above;
iv. All diagnostic tests and/or procedures ordered and/or performed, if any, with results; and
v. A diagnosis.
2. In a hospital or nursing facility setting:
i. An update of symptoms;
ii. An update of physical symptoms;
iii. A resume of findings of procedures, if any done;
iv. Pertinent positive and negative findings of lab, X-ray or any other test;
v. Additional planned studies, if any, and the reason for the studies; and
vi. Treatment changes, if any.
(h) To qualify as documentation that the service was rendered by the APN during an inpatient stay, the medical record shall contain the APN's notes indicating that the APN personally:
1. Reviewed the beneficiary's medical history with the beneficiary and/or his or her family, depending upon the medical situation;
2. Performed a physical examination, as appropriate;
3. Confirmed or revised the diagnosis; and
4. Visited and examined the beneficiary on the days for which a claim for reimbursement is made.
(i) The APN's involvement shall be clearly demonstrated in notes reflecting the APN's personal involvement with, or participation in, the service rendered.
(j) For all EPSDT examinations for individuals under 21 years of age, the following shall be documented in the beneficiary's medical record and shall include:
1. A history (complete initial for new beneficiary, interval for established beneficiary) including past medical history, family history, social history, and systemic review.
2. A developmental and nutritional assessment.
3. A complete, unclothed, physical examination to also include the following:
i. Measurements: height and weight; head circumference to 25 months; blood pressure for children age three or older; and
ii. Vision, dental and hearing screening;
4. The assessment and administration of immunizations appropriate for age and need;
5. Provisions for further diagnosis, treatment and follow-up, by referral if necessary, of all correctable abnormalities uncovered or suspected;
6. Mandatory referral to a dentist for children age three or older (referral to a dentist at or after age one is recommended);
7. The laboratory procedures performed or referred if medically necessary. Recommendations for procedure are as follows:
i. Hemoglobin/Hematocrit three times: six to eight months; two to three or four to six years; and 10 to 12 years.
ii. Urinalysis a minimum of twice: 18 to 24 months and 13 to 15 years.
iii. Tuberculin test (Mantoux): nine to 12 months; and annually thereafter.
iv. Lead screening using blood lead level determinations between nine and 12 months, and again at or about two years of age, and annually up to six years of age. At all other visits, screening shall consist of verbal risk assessment and blood lead level test, as indicated; and
v. Other appropriate screening procedures, if medically necessary (for example: blood cholesterol, test for ova and parasites, STD).
8. Health education and anticipatory guidance; and
9. An offer of social service assistance; and, if requested, referral to a county welfare agency.
(k) The record and documentation of a home visit or house call shall become part of the office progress notes and shall include, as appropriate, the following information:
1. The beneficiary's chief complaint(s), reason for visit;
2. Pertinent medical, family and social history obtained;
3. Pertinent physical findings, including pertinent negative physical findings based on (k)1 and 2;
4. The procedures, if any performed, with results;
5. Lab, X-ray, ECG, etc., ordered with results; and
6. Diagnosis(es) plus treatment plan status relative to present or pre-existing illness(es) plus pertinent recommendations and actions.
