CurrentBlue Cross Blue Shield - TexasPolicy CPCPO29

Medical Record Documentation

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Governs expectations for medical record documentation supporting claims for covered services and applies to providers submitting claims to Blue Cross and Blue Shield of Texas.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyMedical Record Documentation

Policy CodePolicy CPCPO29

Change TypeNo material changes

Effective DateNov 14, 2024

Last ReviewNov 5, 2024

Next Review Date

Key ActionProvider must submit accurate documentation and provide supporting documentation upon request to avoid claim denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24-48 hrsrecommended timeframe to complete documentation

11/05/2024most recent committee approval

CPCPO29policy identifier

Multipleupdate history entries

Documentation Requirements for Coverage and Payment

Documentation criteria for coverage and payment

Documentation must substantiate services billed and support coding and payment.

Medical record must contain relevant history, physical exam, diagnostic/procedure results, and a diagnosis consistent with findings

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

Services on claims and itemized statements must be reflected and supported in the medical documentation; failure to provide supporting documentation may result in processing delays or denial of services

Documentation should be generated at the time of service or as soon as practicable; completion within 24-48 hours is a reasonable expectation

Original records must not be erased; corrections require a single-line strike-through, dated signature, and reason for correction; electronic records must display original and corrected entries with reason and author

Records must be appropriately signed and credentialed; stamped signatures are not acceptable

Templates are discouraged if they limit documentation or encourage cloned entries; records must be patient-specific

All entries must be legible to another reader; illegible records may lead to patient-safety issues and denial

Approved Codes, Coding Guidelines, and Documentation Support Thresholds

Approved code sets and coding guidelinesmixed

industry standard code sets

Requires use of approved code sets (CPT, HCPCS, ICD-10, DRG, NDC) and adherence to coding guidelines and edit protocols.

inv-03: Documentation support threshold

Documentation support thresholdClaims and submitted codes must be supported by medical documentation; lack of proper coding or documentation may result in denial, non-payment, or processing delays.

Scope of supportServices on claim forms and itemized statements must be reflected and supported in the medical record.

Plan rightsThe plan reserves the right to request supporting documentation to determine eligible reimbursement.

Provider Submission and Review Obligations

Documentation Required

Submit accurate documentation and provide supporting records on request

Providers are required to submit accurate medical record documentation to substantiate billed services and coding. Blue Cross and Blue Shield of Texas may request supporting documentation to determine eligible reimbursement, and claims lacking proper coding and documentation may be denied or delayed.

Submit claims using approved industry-standard code sets (CPT, HCPCS, ICD-10, DRG, NDC) and follow coding guidelines and edit protocols.
Provide additional documentation upon request to support coding and payment decisions.
Failure to provide proper documentation may result in claim denial, non-payment, or processing delays.

Definitions and Documentation Notes

inv-05: 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' plus practitioner name and designation).

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

Provider credentialingThe provider's credential must be listed on the medical record (following the signature, in the typed/printed name, or in the letterhead).

inv-06: Addendum

Definition of addendumAn addendum is information added after the original entry to document information not available at the time of the original entry; it should be used sparingly and added timely so the provider can recall encounter details.

Required elements of an addendumMust include a statement that the entry is an addendum, details of the amended information, the date and time of the amendment, and the provider's signature.

Correction vs. addendumCorrections (late entries) must preserve the original entry (single-line strike-through), include a dated signature/initial and reason for correction, and document the correct information with current date and signature; electronic records must similarly show original and corrected entries with reason and author.

inv-07: Cloned/templated records

Definition of cloned/templated recordsCloned, copied, pasted, or carried-forward documentation refers to entries that are identical or nearly identical across visits or patients and is discouraged because records must be patient-specific.

Concerns with templatesTemplates that limit responses (checkboxes, predefined answers) or elicit only selected information may be insufficient to demonstrate coverage and coding requirements and can encourage overdocumentation or non‑patient‑specific entries.

Provider responsibilityEach medical record must be specific to the individual patient; providers are responsible for performing and documenting services, and patient-specific information cannot be copied from another provider without accrediting the original author.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyMedical Record Documentation

Policy CodePolicy CPCPO29

Change TypeNo material changes

Effective DateNov 14, 2024

Last ReviewNov 5, 2024

Next Review Date

Key ActionProvider must submit accurate documentation and provide supporting documentation upon request to avoid claim denial.

SourceLink

On This Page

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Medical Record Documentation

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Sign up for Blue Cross Blue Shield - Texas Policy CPCPO29 alerts

Get alerted when Policy CPCPO29 changes without checking for updates manually.

Monitor payer policy activity

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Governs expectations for medical record documentation supporting claims for covered services and applies to providers submitting claims to Blue Cross and Blue Shield of Texas.

Documentation Requirements for Coverage and Payment

Documentation criteria for coverage and payment

Documentation must substantiate services billed and support coding and payment.

Medical record must contain relevant history, physical exam, diagnostic/procedure results, and a diagnosis consistent with findings

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

Documentation should be generated at the time of service or as soon as practicable; completion within 24-48 hours is a reasonable expectation

Records must be appropriately signed and credentialed; stamped signatures are not acceptable

Templates are discouraged if they limit documentation or encourage cloned entries; records must be patient-specific

All entries must be legible to another reader; illegible records may lead to patient-safety issues and denial

Approved Codes, Coding Guidelines, and Documentation Support Thresholds

Approved code sets and coding guidelinesmixed

industry standard code sets

Requires use of approved code sets (CPT, HCPCS, ICD-10, DRG, NDC) and adherence to coding guidelines and edit protocols.

inv-03: Documentation support threshold

Documentation support thresholdClaims and submitted codes must be supported by medical documentation; lack of proper coding or documentation may result in denial, non-payment, or processing delays.

Scope of supportServices on claim forms and itemized statements must be reflected and supported in the medical record.

Plan rightsThe plan reserves the right to request supporting documentation to determine eligible reimbursement.

Provider Submission and Review Obligations

Documentation Required

Submit accurate documentation and provide supporting records on request

Submit claims using approved industry-standard code sets (CPT, HCPCS, ICD-10, DRG, NDC) and follow coding guidelines and edit protocols.
Provide additional documentation upon request to support coding and payment decisions.
Failure to provide proper documentation may result in claim denial, non-payment, or processing delays.

Definitions and Documentation Notes

inv-05: Signature requirements

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

Provider credentialingThe provider's credential must be listed on the medical record (following the signature, in the typed/printed name, or in the letterhead).

inv-06: Addendum

Required elements of an addendumMust include a statement that the entry is an addendum, details of the amended information, the date and time of the amendment, and the provider's signature.

inv-07: Cloned/templated records