CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP029

Medical Record Documentation

Defines documentation standards and requirements for medical records submitted to Blue Cross and Blue Shield of Oklahoma to support coding and reimbursement; applies to providers submitting claims for covered services under BCBSOK plans.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyMedical Record Documentation

Policy CodePolicy CPCP029

Change TypeNo material change

Effective DateNov 14, 2024

Next Review Date

Key ActionSubmit supporting medical documentation and valid codes when requested to determine reimbursement; failure to provide may result in denial or delays.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24-48hrecommended maximum time to complete documentation after service

11/05/2024Clinical committee approval

11/14/2024Policy effective date

2018-2024policy update history range

Documentation Coverage Criteria

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Documentation must include relevant history, physical examination, diagnostic test(s) and/or procedure results, and a diagnosis consistent with those findings and/or test results.

Services submitted on claim forms and itemized statements must be reflected and supported in the medical documentation; additional documentation requirements may exist in other plan documents.

Submission of any code should be supported by medical documentation; claims that lack proper coding and documentation may result in denial and non-payment.

The plan reserves the right to request supporting documentation to determine eligible reimbursement; failure to provide requested documentation may result in processing delays or denial of services.

Required Codes and Documentation Support

Required code setsmixed

CPT, HCPCS, ICD-10, NDC

Industry-standard code sets required for claim submission

Documentation support requirement

RequirementAny submitted code must be supported by medical documentation; claims that lack proper coding and documentation may result in denial and non-payment.

Provider responsibilityProviders are responsible for submission of accurate documentation of services performed and for submitting claims using valid code combinations from HIPAA-approved code sets (e.g., CPT, HCPCS, ICD-10, NDC).

Review and requestThe plan reserves the right to request supporting documentation to determine eligible reimbursement; providers should submit additional documentation upon request.

Provider Documentation Requests and Claims Review

Documentation Required

Documentation requests and claims review

Providers are responsible for submitting accurate and complete documentation supporting services billed. The plan reserves the right to request supporting documentation to determine eligible reimbursement. Submission of any code should be supported by medical documentation and valid code combinations from HIPAA-approved code sets. Claims should be coded according to industry-standard coding guidelines (for example: UB, AMA CPT, HCPCS, ICD-10-CM/PCS, NDCs, DRG, CMS NCCI/CCI edits).

Claims are subject to code edit protocols and claim review, including benefit coverage terms, provider contract language, medical policies, clinical payment and coding policies, and coding software logic.
Upon request, providers must submit additional documentation to substantiate services billed; failure to provide requested documentation may result in processing delays, denial, or non-payment.
Services submitted on claim forms and itemized statements must be accurately reflected and supported in the medical record.
Claims that lack proper coding and documentation may be denied.
Additional documentation requirements may exist in other plan documents.

Definitions and Documentation Details

Signature requirements

Acceptable signature typesHandwritten signatures, initials over a typed or printed name, or authenticated electronic signatures (typically with date/time and a printed statement such as 'electronically signed by' followed by name/designation).

Electronic signature elementsAn electronic signature usually contains a date and timestamp and a printed statement (e.g., 'electronically signed by' or 'verified/reviewed by') plus the practitioner's name and professional designation.

Unacceptable signaturesStamped signatures and indications such as 'signed but not read' are not acceptable.

Provider credentialThe credential of the provider rendering the service must be listed on the medical record (after the signature, in the typed/printed name, or in the letterhead).

Time-based services documentation

Time documentationFor time-based services, documentation must contain the duration — start and stop times are preferred by the Plan.

Issues addressedDocumentation must list the issues addressed during the time-based service.

Provider signatureThe signature of the service provider must be included on time-based service documentation.

Cloned / templated documentation

DefinitionCloned/copy-pasted documentation is when each entry for a patient is worded exactly alike or when documentation is exactly the same from patient to patient; this is discouraged.

Template cautionTemplates can be useful but should not provide limited options (e.g., checkboxes, predefined answers) that prevent collection of patient-specific detail.

Patient-specificityEvery medical record must be specific to the individual patient and their situation at the time of the encounter; templates should not replace patient-specific detail.

Provider accountabilityProviders remain responsible for performing and documenting the services; patient-specific information cannot be copied from another provider's entry without accrediting the original author.