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Record Keeping and Documentation

Revised: 05-09-2018

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Overview

As a condition of enrollment with Minnesota Health Care Programs (MHCP) and by signing the MHCP Provider Agreement (DHS-4138) districts have agreed to maintain documentation that fully discloses the extent of each health service they provide and that is eligible for MHCP payment. Failure to maintain and document each occurrence may result in MHCP recovering funds already paid.

Health Service Records

Providers must report school-based health-related services in the health services records for a child with an Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP). The documentation must be legible and include:

  • • The medical diagnosis or condition that indicates the need for an IEP
  • • The recipient’s name and date of birth
  • • A current, complete copy of the recipient's IEP or IFSP that documents the type, frequency, duration and scope of the covered IEP services to be provided
  • • A separate treatment plan if IEP or IFSP does not contain measurable outcomes
  • • Copies of any amendments to the IEP or IFSP and individual health plan, plan of care, individual behavior plan, etc.
  • • The recipient's progress or response to treatment, and changes in the treatment or diagnosis
  • • Results of tests or evaluations relating to covered IEP services and copies of evaluations billed as covered IEP services
  • • IEP evaluations, ongoing assessments, diagnostic assessments
  • • Communication with primary care practitioner for PCA services, if applicable
  • • Documentation of the covered IEP services billed (progress notes, trip logs, documentation logs, PCA checklists, supervision documentation and service notes)
  • • Cost documentation required for setting rates
  • Each entry in the health service record must contain:

  • • The recipient's name on each page of the recipient's record
  • • The date on which the entry is made
  • • The date or dates on which the health service is provided
  • • Documentation of the actual services provided (the IEP or IFSP is not sufficient documentation of services provided)
  • • The length of time spent with the recipient, including the start and end time if the amount paid for the service depends on time spent. The cost-based rate for IEP services are calculated by time spent
  • • The signature and title of the person who provided the service
  • • Documentation of required supervision and direction
  • • When applicable, the countersignature of the vendor or supervisor as required
  • • The recipient’s attendance records
  • Additional documentation information:

  • • Do not use pencil, white out, tape, ditto marks, or arrows on health services records. Strikethrough any errors, initial next to the strikethrough and add the corrected information below or next to the strikethrough.
  • • Paper documentation and protected electronic documentation and electronic signatures are acceptable.
  • • It is not necessary to maintain all of the required information in one place, but the information must be available to state and federal auditors or reviewers upon request.
  • The following sections list additional information needed for specific health-related services, including assistive technology devices, special transportation, personal care assistance, and other health-related services, such as, occupational therapy (OT), physical therapy (PT), speech and language pathology and audiology, mental health, nursing and interpreter services.

    In addition to the information in this manual section, refer to the information in the IEP Health-Related Services section for coverage criteria that is specific to the service provided.

    Assistive Technology Devices

    In addition to the information listed in the Health Service Records section, include the following in the health service records:

  • • IEP or IFSP that includes documentation describing the reason(s) why the child needs the device(s) and documentation of medical necessity
  • • Copies of assessments or trials performed to determine the specific device needed, and why this is the most appropriate device for the child’s needs
  • • Invoices or rental agreements for the device, accessories, hardware and software essential to the use device
  • The IEP, an amendment to the IEP, any letter of medical necessity, other documentation, assessments and trials must be completed and dated before the purchase or rental of the device.

    Special Transportation

    In addition to the information listed in the Health Service Records section, include the following in the health service records:

  • • The IEP or IFSP that clearly identifies the specific need or condition that requires the child to need special transportation.
  • • Copies of the completed IEP Services Special Transportation Trip Logs (DHS-5086) or a self-designed trip log that includes all of the same information that is on the DHS-5086 and that DHS approves. Information must include transportation provided under IEP services, with the signature of a person designated by the school (driver, PCA, etc.), who can verify that the child actually received IEP covered transportation services.
  • Personal Care Assistant (PCA) Services

    In addition to the information listed in the Health Service Records section, include the following in the health service records:

  • • Copies of the completed IEP Services Personal Care Assistant Activities Checklist (DHS-4122C) or a self-designed PCA Activities checklist that includes all of the information on the DHS-4122C and that DHS approves. A self-designed checklist must include the following statement (required by Minnesota Statute) in bold black letters above the signature block, “It is a federal crime to provide false information on personal care services billings for medical assistance payment.”
  • • A copy of the care plan or checklist attached to the PCA Activities Checklist with specific descriptions of each actual activity that should be provided to meet the child’s needs and how the service should be provided.
  • • The name, title (Personal Care Assistant, education aide, health aide, etc.) and signature of the main PCA providing this service.
  • • Supervisor’s name, title, signature and date when supervision was provided according to the PCA services supervision schedule.
  • Occupational Therapy (OT), Physical Therapy (PT), Speech and Language Pathology and Audiology, Mental Health, Nursing and Interpreter Services

    In addition to the information listed in the Health Services Records section, include the following in the health services records:

  • • Copies of the completed DHS IEP or IFSP Services Documentation Log (DHS-5085-ENG) (PDF) or the IEP and IFSP Evaluation Documentation Log (DHA-5085A-ENG (PDF), or a self-designed documentation log that includes all of the information requested on the DHS IEP or IFSP documentation log
  • • Documentation of required supervision and supervisor’s name, title and signature when appropriate
  • • Written orders for health-related services that require written orders from a health care professional working within his or her scope of practice
  • • Mental health behavior aide (MHBA) services: Carefully document skills practiced with the child including the number of times the child successfully completed the skill and reasons why the practice session is not successful
  • • An individual behavior plan (IBP) for MHBA services is required in addition to the IEP or IFSP
  • Co-Therapy and Co-Treatment

    Co-therapy may be appropriate when practitioners from different professional disciplines can effectively address their treatment goals while the patient is engaged in a single therapy session. For example, a child may receive treatment from a speech language pathologist while a physical therapist is training the child to use a wheelchair or working with the child to retrain balance to increase independence and mobility. Follow these guidelines for co-therapy:

  • • Provide co-therapy only if the purpose of the treatment is to enhance the quality of the care the child receives, not simply for scheduling convenience
  • • Identify and document the need for co-therapy in the IEP or IFSP
  • • The therapist’s notes and documentation must clearly indicate that the session was co-therapy, the rationale for co-therapy, and identify which goals were addressed through this method
  • • Each practitioner must document co-therapy sessions stating which goals were addressed and the progress made
  • • Limit co-therapy to two disciplines providing treatment during one session
  • • The two therapists must split the session time between the two disciplines when documenting the actual time spent actively engaged with the child (observation, taking turns or waiting for the other therapist is not considered reimbursable time)
  • Co-treatment may be medically necessary for two service providers to care for a child at the same time. This could occur when a second PCA is needed, for the safety of the child and the first PCA, to provide activities of daily living or a behavior intervention or redirection. This could also happen when a nurse needs assistance from a PCA to complete a health-related activity or task. Follow these guidelines for co-treatment:

  • • Providers must identify and document the need for co-treatment in the IEP or IFSP
  • • The plan of care should identify the need and explain how the assist should be performed
  • • Both service providers should document only the time they were face-to-face actively engaged with the child
  • Teaching or training a therapy assistant or PCA is not considered co-therapy or co-treatment. Supervision and other administrative costs are covered by the indirect cost percentage added to the rate for each service and cannot be billed separately.

    Service Time and Encounters

    Districts must accurately track, document and report actual cost data for IEP services that qualified providers provide to MHCP eligible children for whom the district bills. Districts are responsible for all data submitted including data that a billing agent compiles and submits. Maintain back-up documentation of actual costs, service time and encounters. Document required cost data for OT, PT, speech-language pathology and audiology, mental health, nursing and PCA services. Document and report information on eligible children for whom the school bills for each service type listed on IEP Services Annual Data Report Form (DHS-5052) (PDF).

    Effective February 1, 2018, MHCP will require school districts to document start and end times for each IEP or IFSP health-related service covered under Medical Assistance (MA), including MA covered initial evaluations, reevaluations and assessments. This documentation is necessary to accurately reflect the actual amount of face-to-face time the service provider spends with the child.

    The documentation requirements applies to the following IEP health related evaluations, assessments and services:

  • • Physical therapy
  • • Occupational therapy
  • • Speech-language pathology and audiology
  • • Mental health children’s therapeutic services and supports (CTSS)
  • • Nursing
  • • Personal care assistance
  • • Interpreter services
  • PCA exception: Due to the frequency, multiple tasks and behavior episodes that may occur at any time during the school day, it is difficult for PCA providers to keep track of exact times for each task. Because of this, MHCP allows schools to use one of the two methods for documenting PCA time:

  • • Document the face-to-face time spent with the child for each task per day
  • • Conduct a time study to determine the average time per day, per child for the specific PCA tasks for that child **
  • Both options must now include start and end times for the face-to-face time the PCA spends with the child.

    **The requirement for documentation of start and end times for billing PCA services using a time study has been extended until July 1, 2018. MHCP extended the deadline to give schools more time to update their current time studies that do not meet the start and end requirements.

    Document and report direct service time: All face-to-face time spent for covered IEP services provided to each eligible child. Include time for each service provider when two service providers provide services during the same time period. Do not include indirect service time. For example, if both an OT and PT are working with a child, document only the actual face-to-face time for each therapy. Schools cannot bill for overlapping times of two providers or for time spent waiting while the other provider is working with the child.

    Document and report direct encounters: Count each child served once each day per service as an encounter. For example, if a child receives a re-evaluation from the physical therapist in the morning on June 2 and physical therapy from the physical therapy assistant in the afternoon, record one encounter for physical therapy for June 2. Record the time both the physical therapist and the physical therapy assistant spent providing services on June 2.

    Keep the record of the encounter count: Number of encounters per child, per service, per day, time per service, and services by type.

    Record encounters for each eligible child for whom the district bills.

    Review the information in the Covered and Non-covered IEP Health-Related Services section under evaluations, re-evaluations and assessments and the IEP Health-Related Service section that is specific to the service being provided.

    Note: Do not report supervision and direction time. Supervision and direction are covered by the unrestricted indirect cost percentage included in the rate methodology.

    Record Retention

  • Keep all required health services records and all financial records related to the health service that was paid in part by MHCP for at least five years after the initial billing date. Records must include all documentation and recordkeeping requirements for covered IEP services and cost reporting.
  • Schools should also refer to their own record retention schedules. Additional retention requirements may apply for other agencies and situations.

    Resources

    The U. S. Departments of Health and Human Services and Education issued “Joint Guidance on the Application of the Family Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) To Student Health Records” in November 2008. To find the joint guide online, see FERPA-HIPAA (PDF).

    Legal References

    Minnesota Rules 9505.2175 subp. 8 (Health Service Records)
    Minnesota Rules 9505.2190 subp.1 (Retention of Records)

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