This communication supersedes all previous (Bulletins, FAQ, etc) communications regarding this issue.

Section 3410.18 of the standards describes the type of clinical documentation that must be present to support each service that is billed.  Each MHRS provider shall develop and maintain sufficient written clinical documentation to support each therapy, service, activity, or session for which billing is made. Documentation required to support a service claim should at a minimum, include:
(a) The specific service type rendered:
(b) The date, duration, and actual time, a.m. or p.m. (beginning and ending), during which the services were rendered;
(c) Name, title, and credentials of the person providing the services;
(d) The setting in which the services were rendered; and a
(e) Confirmation that the services delivered are contained in the consumer's IRP/IPC
This encounter note is required for every claim.

The encounter note should include specific information about the service intervention(s) used to address IRP/IPC goals and objectives and a detailed description of the consumer’s response to the intervention(s).  The information documented in the encounter note should be sufficient to substantiate the total duration of the service intervention.  To reiterate an encounter note should include a description of the service provided which is sufficient to document that the service was provided in accordance with MHRS regulations and reflects the duration billed; the printed name, title, credential and signature of the person rendering the service; and the date the rendering provider wrote and signed the note.

Encounter notes written by Credentialed Staff do not require a co-signature of a Qualified Practitioner.

Progress notes are defined by MHRS Certification Standards, Section 3410.17 as being written at least once per month and as needed.  Progress notes should be:
• Reflective of progress toward IRP/IPC goals and signed by a Qualified Practitioner.
• A synthesis of the progress towards treatment plan goals for all services provided during the time frame reflected in the progress note.

If a progress note is written by a Credentialed Staff who is not a Qualified Practitioner, the progress note must be counter-signed by a Qualified Practitioner. 

An encounter note may be expanded to serve as the progress note, if
it includes information pertaining to progress toward all treatment plan goals and objectives and is not just documenting the specific service encounter.

If the encounter note is expanded to serve as the progress note then it must be signed by a Qualified Practitioner; if the note is written by a Credentialed Staff a Qualified Practitioner must counter-sign the note. 

Having a Qualified Practitioner co-sign every encounter note does not satisfy the progress note requirement as this does not provide a synthesis of progress towards treatment plan goals.

Please contact your Provider Relations Representative if you have questions regarding this Bulletin.
 

NOTE:  Issued vs.  Effective Date