Adequate medical documentation, psychological well being records. Adequate medical documentation provides the means for measuring the sort, frequency, and period of active treatment mechanisms employed and progress underneath the treatment plan. Under CHAMPUS, it’s required that sufficient and sufficient medical records be kept by the provider to substantiate that specific care was truly and appropriately furnished, was medically or psychologically necessary , and to identify the individual who provided the care. Each service offered or billed have to be documented within the records. In figuring out whether medical records are enough, the data will be reviewed beneath the commonly acceptable requirements (e.g., the standards of an accrediting group permitted by the Director, and the supplier’s state or native licensing requirements) and other necessities specified by this part. The psychiatric and psychological evaluations, physician orders, the remedy plan, integrated progress notes , and the discharge summary are the more critical elements of the mental well being document.

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If the data stipulated beneath paragraph of this section is found not to be correct, the PRO will change the coding and assign the suitable DRG on the basis of the modified coding. Claims for procedures identified by OCHAMPUS as subject to a pattern of abuse shall be the topic of intensified quality assurance evaluation. CHAMPUS admissions in any DRGs which have been specifically recognized by OCHAMPUS for evaluation or which are underneath evaluate for any other purpose. The fiscal year 1988 prevailing cost levels adjusted by the Medicare Economic Index , as the MEI was applied starting in the fiscal yr 1989. This paragraph shall be implemented when CMAC rates are revealed.