Documentation for Medicaid

Medicaid Toolkit

States require documentation for all Medicaid services provided; however, documentation requirements may vary depending on the state and the setting (e.g., school, clinic, or hospital) where the service is provided. State-specific documentation requirements, rules, and guidance can be found in the state's Medicaid plan and/or Medicaid agency guidance documents (e.g., the state provider handbook). One example of a state provider handbook can be found on the Alaska Medicaid website. State associations of audiology and speech-language pathology may meet with local Medicaid agencies and offer to collaborate on manuals and make suggestions for documentation processes that ensure timely reimbursement and limited denials.

Considerations

Prior authorization, if required
Referrals by primary care physicians, if required
Commonly required documentation

evaluation report, diagnosis, reevaluation
claim form requirements

date of service
name of recipient
recipient's identification number
name of provider
provider identification (e.g., National Provider Identifier or NPI, Provider Identification Number or PIN)
provider agency
diagnosis (International Classification of Diseases) and procedure (Current Procedural Terminology or CPT) codes for billing
units of service, if required

additional speech-language pathology requirements

plan of care, individualized education program (IEP), and/or individualized family service plan (IFSP)
recommended frequency and duration of treatment or management of goals/procedures based on a set number of authorized treatments
anticipated outcomes
progress reports
supervision (i.e., requirements for services provided "under the direction of")

Billable codes (some states may restrict use of available CPT codes)
Legislation affecting provision of services

Advocacy

Providers faced with cumbersome paperwork and duplicative data entry may choose to advocate changes in documentation requirements. Many professionals are not aware that the majority of concerns can be addressed at the state level or within the work setting. Some states have published Medicaid provider manuals that list specific requirements for documentation, which can be used to advocate for workplace changes. For example, Virginia offers provider manuals for a variety of settings, including local education agencies, nursing facilities, and early intervention. Other related topics for advocacy include demonstration of medical necessity, sufficiency of IEP, and physician referral.