CurrentAmerigroupPolicy G-11004

Documentation Standards for Episodes of Care

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Defines required medical record documentation elements and standards for episodes of care for providers submitting claims to Amerigroup Community Care; applies to participating and non-participating professional providers and facilities unless overridden by applicable contracts or regulations.

Policy Summary

PayerAmerigroup

PolicyDocumentation Standards for Episodes of Care

Policy CodePolicy G-11004

Change TypeClarificationRemoval (administrative)

Effective DateDec 30, 2024

Last ReviewDec 30, 2024

Next Review Date

Key ActionProvide requested medical records or documentation when Amerigroup requests them to support claims; failure to provide may result in denial, recoupment, or recovery of payment.

SourceLink

POLICY UPDATE CHANGES

Added clarifying language regarding author identification in the medical record, timely entry of information into a medical record, and signature date and time.

Removed recorded start and stop times for time-based procedures.

30 daysmax days to sign documentation

comprehensive listrequired documentation scope

may deny/recoupconsequence if insufficient

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CurrentAmerigroupPolicy G-11004

Documentation Standards for Episodes of Care

Customize your policy alerts

Sign up for Amerigroup Policy G-11004 alerts

Get alerted when Policy G-11004 changes without checking for updates manually.

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Policy Summary

PayerAmerigroup

PolicyDocumentation Standards for Episodes of Care

Policy CodePolicy G-11004

Change TypeClarificationRemoval (administrative)

Effective DateDec 30, 2024

Last ReviewDec 30, 2024

Next Review Date

Key ActionProvide requested medical records or documentation when Amerigroup requests them to support claims; failure to provide may result in denial, recoupment, or recovery of payment.

SourceLink

POLICY UPDATE CHANGES

Added clarifying language regarding author identification in the medical record, timely entry of information into a medical record, and signature date and time.

Removed recorded start and stop times for time-based procedures.

30 daysmax days to sign documentation

comprehensive listrequired documentation scope

may deny/recoupconsequence if insufficient

Documentation Requirements for Episodes of Care

Documentation requirements for episodes of care

Documentation must meet the following standards and include, when applicable, these minimum elements; exceptions apply when provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

ALL of the following

ALL of the following
- Documentation should be legible to someone other than the writer.
ALL of the following
- Documentation should be complete, dated, and timed.
- Timely entry of information into a medical record should be completed at the time of service or shortly thereafter and should not exceed 30 days.
- A signature date within 30 days of the date of service should be included; for services performed in a hospital setting, include signature time on the additional entry.
ALL of the following
- Information identifying the member should be included on each page of the medical record.
- Each entry should include author identification of the physician or other qualified healthcare provider, which may be a handwritten signature, unique electronic identifier, or initials and rendering provider credentials, as applicable.
ALL of the following
- Documentation should reflect all aspects of care.
- Documentation should support the procedure and modifier(s) usage.

ALL of the following

Member identifying information
Consent forms
Health history, including applicable drug allergies
Physical examinations
Physician orders
Immunization records
Medications prescribed

ALL of the following

ANY of the following
- Policies, procedures, and protocols
- Critical incident/occupational health and safety reports
- Statistical and research data
- Clinical assessments
- Published reports/data
Note: Depending on the episode of care, more specific documentation (in compliance with federal and state regulations) may be needed to consider the medical record complete. Providers should refer to standard data elements established by The Joint Commission for specific episodes of care.

ALL of the following

Amerigroup may request that providers submit additional documentation including medical records or other documentation not directly related to the member to support claims.
ANY of the following
- Deny the claim.
- Recover and/or recoup monies previously paid on the claim.
Amerigroup is not liable for interest or penalties when payment is denied or recouped because the provider did not submit required or requested documentation.

ALL of the following

Standard correct coding applies; codes billed must be fully supported in the medical record and/or office notes.
Providers should refer to The Joint Commission and applicable federal/state regulations for episode-specific required data elements.

Required Coding and Support

Required coding systemsmixed

CPT, HCPCS, revenue codes

Industry-standard procedure and revenue coding required on claims and must be supported by medical record documentation.

Coding support (inv-03): documentation requirement for billed codes

RequirementCodes billed (CPT, HCPCS, revenue codes) must be fully supported by documentation in the medical record and/or office notes.

Supported systemsCurrent Procedure Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), and revenue codes are the industry-standard coding systems required on claims.

ConsequencesIf appropriate coding/billing guidelines or current reimbursement policies are not followed, Amerigroup may reject or deny the claim, recover/recoup payment, or adjust reimbursement.

ScopeThis requirement applies to both participating and non‑participating professional providers and facilities unless otherwise noted in the policy or overridden by contracts/regulations.

Documentation Requests and Consequences

Denial Risk

Provide requested documentation or risk denial/recoup

Amerigroup may request additional documentation or medical records to support claims; if the provider fails to provide requested documentation or if the documentation does not support the services billed, Amerigroup may deny the claim and recover or recoup payment. Amerigroup is not liable for interest or penalties when payment is denied or recouped for failure to submit required or requested documentation.

Amerigroup may request additional documentation including medical records or other documentation not directly related to the member to support claims.
If documentation is not provided following the request or if documentation does not support the services billed, Amerigroup may deny the claim and recover and/or recoup monies previously paid.
Amerigroup is not liable for interest or penalties when payment is denied or recouped because the provider did not submit required or requested documentation.

Key Definitions

Episode of Care (inv-05): definition

DefinitionA single episode of care refers to continuous care or a series of intervals of brief separations from care to a member by a provider or facility for the same specific medical problem or condition.

ApplicabilityUsed to group services and documentation that address the same specific medical problem or condition across contiguous encounters or brief separations.

Relation to documentation standardsDocumentation for an episode of care must meet the policy's documentation criteria to support claims and reimbursement determinations.