ODP Releases Interim Technical Guidance for Claim and Service Documentation

The Office of Developmental Programs (ODP) released ODP Bulletin 00-18-04 today with long awaited guidance for claim documentation and service documentation. In anticipation of new regulatory provisions being promulgated, and in order to respond to providers’ requests for guidance until the final rulemaking is effective, ODP is providing interim guidance to providers of Consolidated, Community Living, and P/FDS Waiver services, as well as Targeted Support Management.

The CMS State Medicaid Manual (2497.2) requires accounting records to be supported by appropriate source documentation and be readily available for audit. There are federal and state requirements that documentation is to be available at the time of claim submission. Providers must maintain the documentation used to generate a claim. If the provider does not have this documentation, the claim is not eligible for Federal Financial Participation (FFP) The required documentation must demonstrate that the service is:

• Provided to a Medicaid-eligible individual (Medicaid eligibility can be verified by checking the Eligibility Verification System (EVS));
• Provided by a qualified provider of that service meeting licensing standards;
• Authorized based on assessed need;
• Rendered as authorized in the Individual Support Plan (ISP); and
• Compliant with the Centers for Medicare and Medicaid Services (CMS) State Medicaid Manual, which states that each claim for service must include the following:

1. Date the service was rendered;
2. Name of the recipient;
3. Medicaid identification number, if applicable;
4. Name of the provider agency and person providing the service;
5. Nature, extent, or units of service; and
6. The place(s) the service was rendered.

Pennsylvania requirements in 55 Pa. Code Chapter 1101 specify the documentation requirements for clinical services for the treatment of a medical diagnosis. These requirements must be followed as home and community-based services are covered under the scope of Chapter 1101.

One major component of a claim record is service notes. The provider or common law employer is responsible for ensuring that service notes are completed for each service delivered to an individual. Service notes include information related to the provision of home and community-based services. Service documentation is completed by the person providing the service and is used to record information related to service delivery. The completion of this documentation is typically done during or immediately after the provision of a service.

A service note is to be completed on the day the service is delivered. The provider may choose to enter multiple service notes for multiple services for one individual in the same document or form if all required information is included.

For services that are billed in 15 minute or hour units, a service note is to be completed when services are provided by the same staff person(s) for a continuous span of 15 minute or hour billing units. A continuous span of 15 minute or hour billing units is defined as the uninterrupted provision of a service by the same staff person(s) that is not stopped or discontinued. A new service note must be completed when there is an interruption of service or a change in staff person(s) providing the service within the calendar day.

For services that are billed in day units, a service note must be completed for each day unit that documents the provision of direct or indirect services (such as staff on-call or the use of remote monitoring) for the minimum number of hours required to bill for the day unit. For residential services (Residential Habilitation, Life Sharing and Supported Living) and respite provided in licensed or unlicensed residential settings or other licensed settings (private ICFs/ID, or nursing homes), a service note must be completed for each day unit that documents the provision of at least 8 hours of direct or indirect services. For Respite services provided in private homes that are billed as a day unit, a service note must be completed for each day unit that documents the provision of more than 16 hours of service. When the provider is not rendering direct services to the individual, (the individual is at work, visiting friends, etc.) a new service note is not required to be completed. When there is a change in staff providing a service billed in day units, a new service note is not required when there is a change in the staff providing the service.

The service notes describe service activities and are intended to be an information source to be used by provider staff, the provider, the common law employer or managing employer, and the Supports Coordinator. This information is used to document that the service is being delivered as required in the ISP.

When an individual is self-directing services through the Vendor Fiscal/Employer Agent model, the common law employer is responsible to ensure service notes are completed. The service notes shall be maintained in the individual’s record by the common law employer. When an individual is self-directing services through the Agency with Choice model, the managing employer or the Agency with Choice organization will ensure that service notes are completed. The service notes shall be maintained in the individual’s and Agency with Choice organization’s records.

Supports Coordinators and Targeted Support Managers document service activities that occur with or on behalf of individuals within one business day of the activity. ODP is aware that various methods are used to document these activities such as logs, electronic notes, and recorded documentation completed during service provision and that this documentation is used to complete the Home and Community Services Information System (HCSIS) service notes. Supports Coordination Organizations and TSM providers will continue to complete HCSIS service notes in accordance with ODP guidance and training. Supports Coordinators and Targeted Support Managers have 7 days from the date of contact to enter their service notes into HCSIS.

Some services require progress notes to be completed periodically. Current ODP regulations, 55 Pa. Code § 51.16 (relating to progress notes) describe progress note requirements. Progress notes are typically an assessment written by a program specialist or other provider staff who conduct routine reviews or oversight of staff or during service monitoring. The documentation will indicate whether there has been progress or lack of progress toward the individual’s desired outcomes as stated in the ISP and documentation of restrictive intervention usage as part of the progress notes are to be completed by provider staff. Because a progress note is completed after the provision of services and submission of billing, it is not a requirement for the submission of a claim.

The bulletin provides detailed information regarding the required information necessary for progress notes. The attachment to the bulletin provides interim technical guidance for Claim and Service Documentation by service type and W code.