Common use of Physician Services Clause in Contracts

Physician Services. a. Physician Recordkeeping; general i. All physicians shall keep such legible individual records as are necessary to fully disclose the kind and extent of services provided, as well as the medical necessity for those services. ii. The minimum recordkeeping requirements for services performed in the office, home, residential health care facility, nursing facility (NF), and the hospital setting shall include a progress note in the clinical record for each visit, which supports the procedure code(s) claimed. iii. The progress note shall be placed in the clinical record and retained in the appropriate setting for the service performed. iv. Records of Residential Health Care Facility patients shall be maintained in the physician’s office. v. The required medical records including progress notes, shall be made available, upon their request, to the New Jersey Medicaid/NJ FamilyCare program or its agents. b. Minimum documentation; initial visit; new patient i. The following minimum documentation shall be entered on the medical record, regardless of the setting where the examination is performed, for the service claimed by use of the procedure codes for Initial visit – New patient: 1) Chief complaint(s); 2) Complete history of the present illness and related systemic review, including recordings of pertinent negative findings; 3) Pertinent past medical history; 4) Pertinent family and social history; 5) A record of a full physical examination pertaining to, but not limited to, the history of the present illness and including recordings of pertinent negative findings; 6) Diagnosis(es) and the treatment plan, including ancillary services and medications ordered; 7) Laboratory, X-Rays, electrocardiograms (ECGs), and any other diagnostic tests ordered, with the results; and 8) The specific services rendered and/or modality used (for example, biopsies, injections, individual and/or group psychotherapy, and family therapy). c. Minimum documentation; established patient i. The following minimum documentation shall be entered in the progress notes of the medical record for the service designated by the procedure codes for ESTABLISHED PATIENT; 1) In an office or Residential Health Care Facility: a. The purpose of the visit; b. The pertinent physical, family and social history obtained; c. A record of pertinent physical findings, including pertinent negative findings based upon (a) and (b) above; d. Procedures performed, if any, with results e. Laboratory, X-Ray, electrocardiogram (ECG), or any other diagnostic tests ordered, with the results of the tests; and f. Prognosis and diagnosis. d. Minimum documentation; in home visits and house calls i. For HOME VISIT and HOUSE CALL codes, in addition to the components listed in N.J.A.C. 10:54-2.8, the office progress notes shall include treatment plan status relative to present or pre- existing illness(es), plus pertinent recommendations and actions. e. Minimum documentation; hospital or nursing facility i. In a hospital or nursing facility, documentation shall include: 1) An update of symptoms; 2) An update of physical findings; 3) A resume of findings of procedures, if any are applicable; 4) The pertinent positive and negative findings of laboratory, X-Ray, electrocardiograms (ECGs), or other tests or consultations; 5) Any additional planned studies, if any, including the reasons for any studies; and 6) Treatment changes, if any. f. Minimum documentation; hospital discharge medical summary i. When an inpatient is discharged from the hospital to the care of another medical facility (such as a nursing facility or a community home care agency), a legible discharge and medical summary shall be prepared and signed by the attending physician. ii. The summary should cover the pertinent findings of the history, physical examination, diagnostic and therapeutic modalities, consultations, plan of care or therapy, medications, recommendations for follow-up care and final diagnosis related to the patient’s hospitalization. Recommendations should also be made for further medical care and should be forwarded to the institution or agency to which the patient has been referred or discharged. g. Minimum documentation; mental health services i. For each patient contact made by a physician for psychiatric therapy, written documentation shall be developed and maintained to support each medical or remedial therapy, service, activity, or session for which billing is made. The documentation, at a minimum, shall consist of the following: 1) The specific services rendered and modality used, for example, individual, group, and/or family therapy; 2) The date and the time services were rendered; 3) The duration of services provided, for example, one hour, or one-half hour; 4) The signature of the physician who rendered the service; 5) The setting in which services were rendered; 6) A notation of impediments, unusual occurrences or significant deviations from the treatment described in the Plan of Care; 7) Notations of progress, impediments, treatment, or complications; and 8) Other relevant information, which may include dates or information not included in above, yet important to the clinical picture and prognosis. ii. Clinical progress, complications and treatment which affect prognosis and/or progress shall be documented in the patient’s medical record, as well as any other information important to the clinical picture, therapy, and prognosis. For mental health services that are not specifically included in the patient’s treatment regime, a detailed explanation shall be submitted with the claim form, addressed to the Office of Managed Behavioral Services, Mail Code #25, PO Box 712, Trenton, New Jersey 08625-0712, indicating how these services relate to the treatment regime and objectives in the patient’s plan of care. Similarly, a detailed explanation should accompany bills for medical and remedial therapy, session or encounter that departs from the Plan of Care in terms of need, scheduling, frequency or duration of services furnished (for example, unscheduled emergency services furnished during an acute psychotic episode) explaining why this departure from the established treatment regime is necessary in order to achieve the treatment objectives.

Physician Services. a. Physician Recordkeeping; general i. All physicians shall keep such legible individual records as are necessary to fully disclose the kind and extent of services provided, as well as the medical necessity for those services. ii. The minimum recordkeeping requirements for services performed in the office, home, residential health care facility, nursing facility (NF), and the hospital setting shall include a progress note in the clinical record for each visit, which supports the procedure code(s) claimed. iii. The progress note shall be placed in the clinical record and retained in the appropriate setting for the service performed. iv. Records of Residential Health Care Facility patients shall be maintained in the physician’s office. v. The required medical records including progress notes, shall be made available, upon their request, to the New Jersey Medicaid/NJ FamilyCare program or its agents. b. Minimum documentation; initial visit; new patient i. The following minimum documentation shall be entered on the medical record, regardless of the setting where the examination is performed, for the service claimed by use of the procedure codes for Initial visit – New patient: (1) Chief complaint(s); (2) Complete history of the present illness and related systemic review, including recordings of pertinent negative findings; (3) Pertinent past medical history; (4) Pertinent family and social history; (5) A record of a full physical examination pertaining to, but not limited to, the history of the present illness and including recordings of pertinent negative findings; (6) Diagnosis(es) and the treatment plan, including ancillary services and medications ordered; (7) Laboratory, X-Rays, electrocardiograms (ECGs), and any other diagnostic tests ordered, with the results; and (8) The specific services rendered and/or modality used (for example, biopsies, injections, individual and/or group psychotherapy, and family therapy). c. Minimum documentation; established patient i. The following minimum documentation shall be entered in the progress notes of the medical record for the service designated by the procedure codes for ESTABLISHED PATIENT; (1) In an office or Residential Health Care Facility: a. The purpose of the visit; b. The pertinent physical, family and social history obtained; c. A record of pertinent physical findings, including pertinent negative findings based upon (a) and (b) above; d. Procedures performed, if any, with results e. Laboratory, X-Ray, electrocardiogram (ECG), or any other diagnostic tests ordered, with the results of the tests; and f. Prognosis and diagnosis. d. Minimum documentation; in home visits and house calls i. For HOME VISIT and HOUSE CALL codes, in addition to the components listed in N.J.A.C. 10:54-2.8, the office progress notes shall include treatment plan status relative to present or pre- pre-existing illness(es), plus pertinent recommendations and actions. e. Minimum documentation; hospital or nursing facility i. In a hospital or nursing facility, documentation shall include: (1) An update of symptoms; (2) An update of physical findings; (3) A resume of findings of procedures, if any are applicable; (4) The pertinent positive and negative findings of laboratory, X-Ray, electrocardiograms (ECGs), or other tests or consultations; (5) Any additional planned studies, if any, including the reasons for any studies; and (6) Treatment changes, if any. f. Minimum documentation; hospital discharge medical summary i. When an inpatient is discharged from the hospital to the care of another medical facility (such as a nursing facility or a community home care agency), a legible discharge and medical summary shall be prepared and signed by the attending physician. ii. The summary should cover the pertinent findings of the history, physical examination, diagnostic and therapeutic modalities, consultations, plan of care or therapy, medications, recommendations for follow-up care and final diagnosis related to the patient’s hospitalization. Recommendations should also be made for further medical care and should be forwarded to the institution or agency to which the patient has been referred or discharged. g. Minimum documentation; mental health services i. For each patient contact made by a physician for psychiatric therapy, written documentation shall be developed and maintained to support each medical or remedial therapy, service, activity, or session for which billing is made. The documentation, at a minimum, shall consist of the following: (1) The specific services rendered and modality used, for example, individual, group, and/or family therapy; (2) The date and the time services were rendered; (3) The duration of services provided, for example, one hour, or one-one- half hour; (4) The signature of the physician who rendered the service; (5) The setting in which services were rendered; (6) A notation of impediments, unusual occurrences or significant deviations from the treatment described in the Plan of Care; (7) Notations of progress, impediments, treatment, or complications; and (8) Other relevant information, which may include dates or information not included in above, yet important to the clinical picture and prognosis. ii. Clinical progress, complications and treatment which affect prognosis and/or progress shall be documented in the patient’s medical record, as well as any other information important to the clinical picture, therapy, and prognosis. For mental health services that are not specifically included in the patient’s treatment regime, a detailed explanation shall be submitted with the claim form, addressed to the Office of Managed Behavioral Services, Mail Code #25, PO Box 712, Trenton, New Jersey 08625-0712, indicating how these services relate to the treatment regime and objectives in the patient’s plan of care. Similarly, a detailed explanation should accompany bills for medical and remedial therapy, session or encounter that departs from the Plan of Care in terms of need, scheduling, frequency or duration of services furnished (for example, unscheduled emergency services furnished during an acute psychotic episode) explaining why this departure from the established treatment regime is necessary in order to achieve the treatment objectives.

Physician Services. a. Physician Recordkeeping; general i. All physicians shall keep such legible individual records as are necessary to fully disclose the kind and extent of services provided, as well as the medical necessity for those services. ii. The minimum recordkeeping requirements for services performed in the office, home, residential health care facility, nursing facility (NF), and the hospital setting shall include a progress note in the clinical record for each visit, which supports the procedure code(s) claimed. iii. The progress note shall be placed in the clinical record and retained in the appropriate setting for the service performed. iv. Records of Residential Health Care Facility patients shall be maintained in the physician’s office. v. The required medical records including progress notes, shall be made available, upon their request, to the New Jersey Medicaid/NJ FamilyCare program or its agents. b. Minimum documentation; initial visit; new patient i. The following minimum documentation shall be entered on the medical record, regardless of the setting where the examination is performed, for the service claimed by use of the procedure codes for Initial visit – New patient: (1) Chief complaint(s); (2) Complete history of the present illness and related systemic review, including recordings of pertinent negative findings; (3) Pertinent past medical history; (4) Pertinent family and social history; (5) A record of a full physical examination pertaining to, but not limited to, the history of the present illness and including recordings of pertinent negative findings; (6) Diagnosis(es) and the treatment plan, including ancillary services and medications ordered; (7) Laboratory, X-Rays, electrocardiograms (ECGs), and any other diagnostic tests ordered, with the results; and (8) The specific services rendered and/or modality used (for example, biopsies, injections, individual and/or group psychotherapy, and family therapy). c. Minimum documentation; established patient i. The following minimum documentation shall be entered in the progress notes of the medical record for the service designated by the procedure codes for ESTABLISHED PATIENT; (1) In an office or Residential Health Care Facility: a. The purpose of the visit; b. The pertinent physical, family and social history obtained; c. A record of pertinent physical findings, including pertinent negative findings based upon (a) and (b) above; d. Procedures performed, if any, with results e. Laboratory, X-Ray, electrocardiogram (ECG), or any other diagnostic tests ordered, with the results of the tests; and f. Prognosis and diagnosis. d. Minimum documentation; in home visits and house calls i. For HOME VISIT and HOUSE CALL codes, in addition to the components listed in N.J.A.C. 10:54-2.8, the office progress notes shall include treatment plan status relative to present or pre- existing illness(es), plus pertinent recommendations and actions. e. Minimum documentation; hospital or nursing facility i. In a hospital or nursing facility, documentation shall include: (1) An update of symptoms; (2) An update of physical findings; (3) A resume of findings of procedures, if any are applicable; (4) The pertinent positive and negative findings of laboratory, X-Ray, electrocardiograms (ECGs), or other tests or consultations; (5) Any additional planned studies, if any, including the reasons for any studies; and (6) Treatment changes, if any. f. Minimum documentation; hospital discharge medical summary i. When an inpatient is discharged from the hospital to the care of another medical facility (such as a nursing facility or a community home care agency), a legible discharge and medical summary shall be prepared and signed by the attending physician. ii. The summary should cover the pertinent findings of the history, physical examination, diagnostic and therapeutic modalities, consultations, plan of care or therapy, medications, recommendations for follow-up care and final diagnosis related to the patient’s hospitalization. Recommendations should also be made for further medical care and should be forwarded to the institution or agency to which the patient has been referred or discharged. g. Minimum documentation; mental health services i. For each patient contact made by a physician for psychiatric therapy, written documentation shall be developed and maintained to support each medical or remedial therapy, service, activity, or session for which billing is made. The documentation, at a minimum, shall consist of the following: (1) The specific services rendered and modality used, for example, individual, group, and/or family therapy; (2) The date and the time services were rendered; (3) The duration of services provided, for example, one hour, or one-half hour; (4) The signature of the physician who rendered the service; (5) The setting in which services were rendered; (6) A notation of impediments, unusual occurrences or significant deviations from the treatment described in the Plan of Care; (7) Notations of progress, impediments, treatment, or complications; and (8) Other relevant information, which may include dates or information not included in above, yet important to the clinical picture and prognosis. ii. Clinical progress, complications and treatment which affect prognosis and/or progress shall be documented in the patient’s medical record, as well as any other information important to the clinical picture, therapy, and prognosis. For mental health services that are not specifically included in the patient’s treatment regime, a detailed explanation shall be submitted with the claim form, addressed to the Office of Managed Behavioral Services, Mail Code #25, PO Box 712, Trenton, New Jersey 08625-0712, indicating how these services relate to the treatment regime and objectives in the patient’s plan of care. Similarly, a detailed explanation should accompany bills for medical and remedial therapy, session or encounter that departs from the Plan of Care in terms of need, scheduling, frequency or duration of services furnished (for example, unscheduled emergency services furnished during an acute psychotic episode) explaining why this departure from the established treatment regime is necessary in order to achieve the treatment objectives.

Physician Services. a. Physician Recordkeeping; general i. All physicians shall keep such legible individual records as are necessary to fully disclose the kind and extent of services provided, as well as the medical necessity for those services. ii. The minimum recordkeeping requirements for services performed in the office, home, residential health care facility, nursing facility (NF), and the hospital setting shall include a progress note in the clinical record for each visit, which supports the procedure code(s) claimed. iii. The progress note shall be placed in the clinical record and retained in the appropriate setting for the service performed. iv. Records of Residential Health Care Facility patients shall be maintained in the physician’s office. v. The required medical records including progress notes, shall be made available, upon their request, to the New Jersey Medicaid/NJ FamilyCare program or its agents. b. Minimum documentation; initial visit; new patient i. The following minimum documentation shall be entered on the medical record, regardless of the setting where the examination is performed, for the service claimed by use of the procedure codes for Initial visit – New patient: (1) Chief complaint(s); (2) Complete history of the present illness and related systemic review, including recordings of pertinent negative findings; (3) Pertinent past medical history; (4) Pertinent family and social history; (5) A record of a full physical examination pertaining to, but not limited to, the history of the present illness and including recordings of pertinent negative findings; (6) Diagnosis(es) and the treatment plan, including ancillary services and medications ordered; (7) Laboratory, X-Rays, electrocardiograms (ECGs), and any other diagnostic tests ordered, with the results; and (8) The specific services rendered and/or modality used (for example, biopsies, injections, individual and/or group psychotherapy, and family therapy). c. Minimum documentation; established patient i. The following minimum documentation shall be entered in the progress notes of the medical record for the service designated by the procedure codes for ESTABLISHED PATIENT; (1) In an office or Residential Health Care Facility: a. The purpose of the visit; b. The pertinent physical, family and social history obtained; c. A record of pertinent physical findings, including pertinent negative findings based upon (a) and (b) above; d. Procedures performed, if any, with results e. Laboratory, X-Ray, electrocardiogram (ECG), or any other diagnostic tests ordered, with the results of the tests; and f. Prognosis and diagnosis. d. Minimum documentation; in home visits and house calls i. For HOME VISIT and HOUSE CALL codes, in addition to the components listed in N.J.A.C. 10:54-2.8, the office progress notes shall include treatment plan status relative to present or pre- pre-existing illness(es), plus pertinent recommendations and actions. e. Minimum documentation; hospital or nursing facility i. In a hospital or nursing facility, documentation shall include: (1) An update of symptoms; (2) An update of physical findings; (3) A resume of findings of procedures, if any are applicable; (4) The pertinent positive and negative findings of laboratory, X-Ray, electrocardiograms (ECGs), or other tests or consultations; (5) Any additional planned studies, if any, including the reasons for any studies; and (6) Treatment changes, if any. f. Minimum documentation; hospital discharge medical summary i. When an inpatient is discharged from the hospital to the care of another medical facility (such as a nursing facility or a community home care agency), a legible discharge and medical summary shall be prepared and signed by the attending physician. ii. The summary should cover the pertinent findings of the history, physical examination, diagnostic and therapeutic modalities, consultations, plan of care or therapy, medications, recommendations for follow-up care and final diagnosis related to the patient’s hospitalization. Recommendations should also be made for further medical care and should be forwarded to the institution or agency to which the patient has been referred or discharged. g. Minimum documentation; mental health services i. For each patient contact made by a physician for psychiatric therapy, written documentation shall be developed and maintained to support each medical or remedial therapy, service, activity, or session for which billing is made. The documentation, at a minimum, shall consist of the following: (1) The specific services rendered and modality used, for example, individual, group, and/or family therapy; (2) The date and the time services were rendered; (3) The duration of services provided, for example, one hour, or one-half onehalf hour; (4) The signature of the physician who rendered the service; (5) The setting in which services were rendered; (6) A notation of impediments, unusual occurrences or significant deviations from the treatment described in the Plan of Care; (7) Notations of progress, impediments, treatment, or complications; and (8) Other relevant information, which may include dates or information not included in above, yet important to the clinical picture and prognosis. ii. Clinical progress, complications and treatment which affect prognosis and/or progress shall be documented in the patient’s medical record, as well as any other information important to the clinical picture, therapy, and prognosis. For mental health services that are not specifically included in the patient’s treatment regime, a detailed explanation shall be submitted with the claim form, addressed to the Office of Managed Behavioral Services, Mail Code #25, PO Box 712, Trenton, New Jersey 08625-0712, indicating how these services relate to the treatment regime and objectives in the patient’s plan of care. Similarly, a detailed explanation should accompany bills for medical and remedial therapy, session or encounter that departs from the Plan of Care in terms of need, scheduling, frequency or duration of services furnished (for example, unscheduled emergency services furnished during an acute psychotic episode) explaining why this departure from the established treatment regime is necessary in order to achieve the treatment objectives.

Physician Services. a. Physician Recordkeeping; general i. All physicians shall keep such legible individual records as are necessary to fully disclose the kind and extent of services provided, as well as the medical necessity for those services. ii. The minimum recordkeeping requirements for services performed in the office, home, residential health care facility, nursing facility (NF), and the hospital setting shall include a progress note in the clinical record for each visit, which supports the procedure code(s) claimed. iii. The progress note shall be placed in the clinical record and retained in the appropriate setting for the service performed. iv. Records of Residential Health Care Facility patients shall be maintained in the physician’s 's office. v. The required medical records including progress notes, shall be made available, upon their request, to the New Jersey Medicaid/NJ FamilyCare program or its agents. b. Minimum documentation; initial visit; new patient i. The following minimum documentation shall be entered on the medical record, regardless of the setting where the examination is performed, for the service claimed by use of the procedure codes for Initial visit – visit--New patient: (1) Chief complaint(s); (2) Complete history of the present illness and related systemic review, including recordings of pertinent negative findings; (3) Pertinent past medical history; (4) Pertinent family and social history; (5) A record of a full physical examination pertaining to, but not limited to, the history of the present illness and including recordings of pertinent negative findings; (6) Diagnosis(es) and the treatment plan, including ancillary services and medications ordered; (7) Laboratory, X-Rays, electrocardiograms (ECGs), and any other diagnostic tests ordered, with the results; and (8) The specific services rendered and/or modality used (for example, biopsies, injections, individual and/or group psychotherapy, and family therapy). c. Minimum documentation; established patient i. The following minimum documentation shall be entered in the progress notes of the medical record for the service designated by the procedure codes for ESTABLISHED PATIENT;: (1) In an office or Residential Health Care Facility: a. (a) The purpose of the visit; b. (b) The pertinent physical, family and social history obtained; c. (c) A record of pertinent physical findings, including pertinent negative findings based upon (a) and (b) above; d. (d) Procedures performed, if any, with results; e. (e) Laboratory, X-Ray, electrocardiogram (ECG), or any other diagnostic tests ordered, with the results of the tests; and f. (f) Prognosis and diagnosis. d. Minimum documentation; in home visits and house calls i. For HOME VISIT and HOUSE CALL codes, in addition to the components listed in N.J.A.C. 10:54-2.8, the office progress notes shall include treatment plan status relative to present or pre- pre-existing illness(es), plus pertinent recommendations and actions. e. Minimum documentation; hospital or nursing facility i. In a hospital or nursing facility, documentation shall include: (1) An update of symptoms; (2) An update of physical findings; (3) A resume of findings of procedures, if any are applicable; (4) The pertinent positive and negative findings of laboratory, X-Ray, electrocardiograms (ECGs), or other tests or consultations; (5) Any additional planned studies, if any, including the reasons for any studies; and (6) Treatment changes, if any. f. Minimum documentation; hospital discharge medical summary i. When an inpatient is discharged from the hospital to the care of another medical facility (such as a nursing facility or a community home care agency), a legible discharge and medical summary shall be prepared and signed by the attending physician. ii. The summary should cover the pertinent findings of the history, physical examination, diagnostic and therapeutic modalities, consultations, plan of care or therapy, medications, recommendations for follow-up care and final diagnosis related to the patient’s 's hospitalization. Recommendations should also be made for further medical care and should be forwarded to the institution or agency to which the patient has been referred or discharged. g. Minimum documentation; mental health services i. For each patient contact made by a physician for psychiatric therapy, written documentation shall be developed and maintained to support each medical or remedial therapy, service, activity, or session for which billing is made. The documentation, at a minimum, shall consist of the following: (1) The specific services rendered and modality used, for example, individual, group, and/or family therapy; (2) The date and the time services were rendered; (3) The duration of services provided, for example, one hour, or one-one- half hour; (4) The signature of the physician who rendered the service; (5) The setting in which services were rendered; (6) A notation of impediments, unusual occurrences or significant deviations from the treatment described in the Plan of Care; (7) Notations of progress, impediments, treatment, or complications; and (8) Other relevant information, which may include dates or information not included in above, yet important to the clinical picture and prognosis. ii. Clinical progress, complications and treatment which affect prognosis and/or progress shall be documented in the patient’s 's medical record, as well as any other information important to the clinical picture, therapy, and prognosis. For mental health services that are not specifically included in the patient’s 's treatment regime, a detailed explanation shall be submitted with the claim form, addressed to the Office of Managed Behavioral Services, Mail Code #25, PO Box 712XX Xxx 000, TrentonXxxxxxx, New Jersey 08625Xxx Xxxxxx 00000-07120000, indicating how these services relate to the treatment regime and objectives in the patient’s 's plan of care. Similarly, a detailed explanation should accompany bills for medical and remedial therapy, session or encounter that departs from the Plan of Care in terms of need, scheduling, frequency or duration of services furnished (for example, unscheduled emergency services furnished during an acute psychotic episode) explaining why this departure from the established treatment regime is necessary in order to achieve the treatment objectives.