Clinical records and Fiscal records Guidelines


The following table contains general guidelines for clinical documentation that must be maintained by all providers except nursing facilities. Clinical records other than those listed may also be needed to clearly document all information pertinent to services that are rendered to beneficiaries. All providers must refer to their specific coverage policy in this manual for additional documentation requirements. The clinical record must be sufficiently detailed to allow reconstruction of what transpired for each service billed. All documentation for services provided must be signed and dated by the rendering health care professional.

For services that are time-specific according to the procedure code billed, providers must indicate in the medical record the actual begin time and end time of the particular service. For example, some Physical Medicine procedure codes specify per 15 minutes. If the procedure started at 3:00 p.m. and ended at 3:15 p.m., the begin time and end time must be recorded in the medical record.

The medical record must indicate the specific findings or results of diagnostic or therapeutic procedures. If an abbreviation, symbol, or other mark is used, it must be standard, widely accepted health care terminology. Symbols, marks, etc. unique to that provider must not be used.


** When a test is performed, at a minimum, the test value for that beneficiary for that test must be noted. Additionally, the normal range of values for the testing methodology should be annotated in the record.

** When an x-ray is taken, the results or findings must be indicated. For example, a chest x-ray may indicate "no pulmonary edema present" or "no consolidation."

** When a physical examination is performed, pertinent results or readings must appear.

** If blood pressure is taken, the actual reading must appear.

** If heart, lungs, eyes, etc. are checked, the results or findings must be detailed.

** Medical/surgical procedures performed must be sufficiently documented to allow another professional to reconstruct what transpired (e.g., "I-D" is not sufficient documentation).

** When a complete physical exam is rendered, the level of service must be fully documented.

** If private duty nursing is provided, the care provided during each hour must be fully detailed.

Hospitals must retain any clinical information required to comply with 42 CFR 482.24. A nursing facility must retain any clinical information required to comply with 42 CFR 483.75 and the plan of care must comply with 42 CFR 483.20(d). These regulations are available from MDHHS or Centers for Medicare & Medicaid Services (CMS). (Hospitals and nursing facilities should refer to the Reimbursement Appendix of their chapters in this manual for additional record keeping requirements.)


The following fiscal records must be maintained:

** Copies of Remittance Advices (RA);

** PA requests and approvals for services and supplies (including managed care authorizations);

** Verification of medical necessity and the provider's usual and customary charge for the noncovered service;

** Record of third-party payments; and

** Copies of purchase invoices for items offered or supplied to the beneficiary.


Providers must maintain, in English and in a legible manner, written or electronic records necessary to fully disclose and document the extent of services provided to beneficiaries. Necessary records include fiscal and clinical records as discussed below. Appointment books and any logs are also considered a necessary record if the provider renders a service that is time-specific according to the procedure code billed. Examples of services that are time-specific are psychological testing (per hour), medical psychotherapy (20-30 minutes), and vision orthoptic treatment (30 minutes). The records are to be retained for a period of not less than seven years from the DOS, regardless of change in ownership or termination of participation in Medicaid for any reason. This requirement is also extended to any subcontracted provider with which the provider has a business relationship.


Providers arranging or rendering services upon the order, prescription or referral of another provider (e.g., physician) must maintain that order, prescription and/or referral for a period of seven years.


Providers must retain the following beneficiary identification information in their records:

** Name

** Medicaid ID number

** Medical record number

** Address, including zip code

** Birth date

** Telephone number, if available

** Any private health insurance information for the beneficiary, if available


Providers are required to permit MDHHS personnel, or authorized agents, access to all information concerning any services that may be covered by Medicaid. This access does not require an authorization from the beneficiary because the purpose for the disclosure is permitted under the HIPAA Privacy rule. Health plans contracting with the MDHHS must be permitted access to all information relating to services reimbursed by the health plan.

Providers must, upon request from authorized agents of the state or federal government, make available for examination and photocopying all medical records, quality assurance documents, financial records, administrative records, and other documents and records that must be maintained. (Failure to make requested records available for examination and duplication and/or extraction through the method determined by authorized agents of the state or federal government may result in the provider's
suspension and/or termination from Medicaid.) Records may only be released to other individuals if they have a release signed by the beneficiary authorizing access to his records or if the disclosure is for a permitted purpose under all applicable confidentiality laws.


MDHHS complies with HIPAA Privacy requirements and recognizes the concern for the confidential relationship between the provider and the beneficiary and protects this relationship using the minimum amount of information necessary for purposes directly related to the administration of Medicaid. All records are of a confidential nature and should not be released, other than to a beneficiary or his representative, unless the provider has a signed release from the beneficiary or the disclosure is for a permitted purpose under all applicable confidentiality laws (refer to the Availability of Records subsection of this chapter for additional information). Providers are bound to all HIPAA privacy and security requirements as federally mandated.

If the provider receives a court order, a subpoena, beneficiary request, or other authorized request for medical bills, payment, or claims adjudication information, the information should be released. At the same time, copies of the court order, subpoena, beneficiary request, other authorized request, and any additional information should be faxed to the MDHHS TPL Section. (Refer to the Directory Appendix for contact information.)

If there is a reason to suspect a duplicate payment has been or will be made, but the payment is not assigned, the provider should contact the TPL Section. TPL will make the necessary arrangements to collect the duplicate payment from the third-party source.

If the provider questions the appropriateness of releasing beneficiary records, he is encouraged to seek legal counsel before doing so.

ICD 10 code for dysphagia - R13

Diseases of the blood and blood-forming organs and certain disorders involving the forming organs and certain disorders involving the forming organs and certain disorders involving the immune mechanism (D50- immune mechanism (D50-D89)

Iron deficiency anemia (D50)

Iron deficiency anemia secondary to blood loss (chronic) (D50.0)

Sideropenic dysphagia (D50.1)

Other iron deficiency anemias (D50.8)

Iron deficiency anemia, unspecified (D50.9)

Vitamin B12 deficiency anemia (D51)

Vitamin B12 deficiency anemia due to intrinsic factor deficiency (D51.0)

Vitamin B12 deficiency anemia due to selective vitamin B12 malabsorption with proteinuria (D51.1)

Transcobalamin II deficiency (D51.2)

Other dietary vitamin B12 deficiency anemia (D51.3)

Other vitamin B12 deficiency anemias (D51.8)

Vitamin B12 deficiency anemia, unspecified (D51.9)

Folate deficiency anemia (D52)

Dietary folate deficiency anemia (D52.0)

Nausea and vomiting (R11)

Heartburn (R12)

Dysphagia (R13)

Flatulence and related conditions (R14)

Fecal incontinence (R15)

Drug-induced folate deficiency anemia (D52.1)

Other folate deficiency anemias (D52.8)

Folate deficiency anemia, unspecified (D52.9)

Other nutritional anemias (D53)

Protein deficiency anemia (D53.0)

Other megaloblastic anemias, not elsewhere classified (D53.1)

Scorbutic anemia (D53.2)

Other specified nutritional anemias (D53.8)

Nutritional anemia, unspecified (D53.9)

Iron deficiency

Originally described in the context of sideropenic dysphagia, it is an important cause of epithelial atrophy. The association of iron deficiency with oropharyngeal squamous cell carcinomas has been observed since the mid-thirties of the 20th century {21}. However, a significant decrease of cases with hypopharyngeal cancers and iron deficiency was noted in Sweden in the seventies {1433}. Few cases of oral cancer and iron deficiency have been published in the last 20 years.

Mucoepidermoid carcinoma

This most common malignant salivary gland tumour involves minor glands, and accounts for 9.5-23% of all minor gland tumours {669,704,2711}. About half of the cases arise in the palate and other common sites include the buccal mucosa, lips, floor of oral cavity and retromolar pad. They appear to be much more frequent in the lower lip than the upper lip {1871}. The tumour is often asymptomatic and detected during a routine dental examination.Many appear as bluish, domed swellings that resemble mucoceles or haemangiomas. Less commonly, the surface appears granular or papillary. Tumours of the base of tongue or oropharynx may cause dysphagia and sublingual tumours can lead to ankyloglossia and dysphonia. High-grade tumours are uncommon but can result in ulceration, loosening of teeth, paraesthesia or anaesthesia. Mucoepidermoid carcinoma is the most common salivary gland tumour to develop in a central location within the bone of the mandible or, less frequently, the maxilla {280}. The microscopical features of minor gland mucoepidermoid carcinomas are the same as those seen in the major glands.

Clinical features

Patients with NHL of the lip, buccal mucosa, gingiva, floor of mouth, tongue or palate usually present with ulcer, swelling, discoloration, pain, paraesthesia, anaesthesia, or loose teeth. Those with NHL of the Waldeyer ring (tonsils) or oropharynx usually present with a sensation of fullness of the throat, sore throat, dysphagia, or snoring. The high-grade tumours often show rapid growth. Systemic symptoms such as fever and night sweat are uncommon {201}.

Clinical examination reveals solitary or multiple lesions, in the form of an exophytic mass, ulcer or localized swelling. Some cases may mimic inflammatoryconditions, such as periodontitis.

Tonsillar lymphoma usually manifests as asymmetric tonsil enlargement, although the disease can be bilateral in up to 9% of cases {2250}. The regional lymph nodes can be enlarged as a result of lymphoma involvement or reactive changes secondary to ulceration.


Claim Determinations

When BCBSTX receives a properly submitted claim, it has authority and discretion under the Plan to interpret and determine benefits in accordance with the Plan provisions. BCBSTX will render an initial decision to pay or deny a claim within 30 days of receipt of the claim. If BCBSTX requires further information in order to process the claim, we will request it within that 30-day period.

You have the right to seek and obtain a full and fair review by BCBSTX of any determination of a claim, any determination of a request for preauthorization, or any other determination made by BCBSTX of your benefits under the Plan.

If a Claim Is Denied or Not Paid in Full

On occasion, BCBSTX may deny all or part of your claim. There are a number of reasons why this may happen. We suggest that you first read the Explanation of Benefits summary prepared by BCBSTX; then review this Benefit Booklet to see whether you understand the reason for the determination. If you have additional information that you believe could change the decision, send it to BCBSTX and request a review of the decision. Include your full name, group and subscriber numbers with the request.

If the claim is denied in whole or in part, you will receive a written notice from BCBSTX with the following information, if applicable:

The reasons for denial;

A reference to the health care plan provisions on which the denial is based;

A description of additional information which may be necessary to complete the claim and an explanation of why such information is necessary; and

An explanation of how you may have the claim reviewed by BCBSTX if you do not agree with the denial.

Right to Review Claim Determinations

If you believe BCBSTX incorrectly denied all or part of your benefits, you may have your claim reviewed.
BCBSTX will review its decision in accordance with the following procedure:

Within 180 days after you receive notice of a denial or partial denial, write to BCBSTX's Administrative Office. BCBSTX will need to know the reasons why you do not agree with the denial or partial denial. Send your request to:

Claim Review Section

Blue Cross and Blue Shield of Texas
P. O. Box 660044
Dallas, Texas 75266-0044

You may also designate a representative to act for you in the review procedure. Your designation of a representative must be in writing as it is necessary to protect against disclosure of information about you except to your authorized representative.

BCBSTX will honor telephone requests for information, however, such inquiries will not constitute a request for review.

You and your authorized representative may ask to see relevant documents and may submit written issues, comments and additional medical information within 180 days after you receive notice of a denial or partial denial. BCBSTX will give you a written decision within 60 days after it receives your request for review.

If you have any questions about the claims procedures or the review procedure, write to BCBSTX's Administrative Office or call the toll-free Customer Service Helpline number shown in this Benefit Booklet or on your Identification Card.

If you have a claim for benefits which is denied or ignored, in whole or in part, and your Plan is governed by the Employee Retirement Income Security Act (ERISA), you may file suit under 502 (a) of ERISA.

CPT 88305, 88307 - Surgical pathology billing procedure codes

Procedure Code Description

88305 Level IV surgical pathology, gross and microscopic examination…prostate needle biopsy…

88307 (Level V -surgical pathology, gross and microscopic examination)

G0416 Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method, 10-20 specimens

G0417 Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, 21-40 specimens

G0418 Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, 41-60 specimens

G0419 Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, >60 specimens

Surgical Pathology and Related Prostate Needle Biopsy


Surgical pathology involves the gross and microscopic examination by surgical (e.g., dermatologists) and non-surgical providers (e.g., pathologists) of surgical or biopsy specimens. The practice of surgical pathology allows for definitive diagnosis of disease (or lack thereof) in cases where tissue is surgically removed from a patient. This is usually performed by a combination of gross (i.e., macroscopic) and histologic (i.e., microscopic) examination of the tissue, and may involve evaluations of molecular properties of the tissue by immunohistochemistry or other laboratory tests. This policy applies to all professional providers billing Current Procedural Terminology (CPT®′) or Healthcare Common Procedure Coding System (HCPCS Level II) codes on a Form CMS-1500 for multiple surgical pathology services for prostate needle biopsy


A prostate needle biopsy commonly occurs based on the detection of elevated prostate-specific antigen (PSA) performed as part of prostate cancer screening. Typically, the initial biopsy consists of a small number of core specimens taken of the prostate. Individuals with an elevated PSA level but with a normal initial biopsy often undergo repeat biopsy evaluation. Prostate saturation biopsy, also referred to as prostate saturation needle biopsy, involves taking numerous samples of prostate tissue, typically 20 to 40 cores, in order to increase the likelihood of detecting prostate cancer in a subgroup of high-risk individuals in whom previous conventional
prostate biopsies have been negative.

CPT code 88305 describes level IV surgical pathology, gross and microscopic examination. When the operating provider or pathologist examines multiple, separate tissue samples on the same date of service for the same patient, the procedure code is reported using either multiple units or line items and may include any appropriate modifier(s). When the tissue samples are for prostate tissue, HCPCS lists procedure codes G0416-G0419 for 10 or more specimens in various increments for prostate needle biopsy. Therefore, the Health Plan will apply a frequency limit of nine units per date of service for CPT code 88305 when reported with a prostate diagnosis. When CPT code 88305 is reported in excess of nine units on the same date of service with a prostate diagnosis, the code will not be eligible for reimbursement.

Billing and Reimbursement of Prostate Biopsy Services

Effective September 1, 2012, the global reimbursement for professional pathology services for prostate biopsy codes 88305 and 88307 will be capped at nine units.

Professional pathology services must be billed as a global charge when billing for both the technical and professional components. Healthcare Common Procedure Coding System (HCPCS) code G0416 should also be considered when billing for examination of prostate biopsy samples.

Payment Edit rules

88300 (Level I -surgical pathology, gross examination only) bundles with 88302 (Level II -Surgical pathology, gross and microscopic examination), 88304 (Level III -surgical pathology, gross and microscopic examination), 88305 (Level IV -surgical pathology, gross and microscopic examination),

88307 (Level V -surgical pathology, gross and microscopic examination) and 88309 (Level VI - surgical pathology, gross and microscopic examination).


Redundant/Mutually Exclusive 88302

Surgical Pathology Services payment Guide from Medicare

Surgical pathology services include the gross and microscopic examination of organ tissue performed by a physician, except for autopsies, which are not covered by Medicare. Surgical pathology services paid under the physician fee schedule are reported under the following CPT codes:

88300, 88302, 88304, 88305, 88307, 88309, 88311, 88312, 88313, 88314, 88318, 88319, 88321, 88323, 88325, 88329, 88331, 88332, 88342, 88346, 88347, 88348, 88349, 88355, 88356, 88358, 88361, 88362, 88365, 88380.

Depending upon circumstances and the billing entity, the carriers may pay professional component, technical component or both.

CPT code 15734, 15732, 15740 - Muscle, mycoutaneos procedure

15570* Formation of direct or tubed pedicle, with or without transfer; trunk

15731* Forehead flap with preservation of vascular pedicle (e.g., axial pattern flap, paramedian forehead flap)

15732* Muscle, myocutaneous, or fasciocutaneous flap; head and neck (e.g., temporalis, masseter muscle, sternocleidomastoid, levator scapulae)

15734* Muscle, myocutaneous, or fasciocutaneous flap; trunk

15736* Muscle, myocutaneous, or fasciocutaneous flap; upper extremity

15738* Muscle, myocutaneous, or fasciocutaneous flap; lower extremity

15740* Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel

15756* Free muscle or myocutaneous flap with microvascular anastomosis


Congenital Anomaly: A physical developmental defect that is present at the time of birth, and that is identified within the first twelve months of birth. Cosmetic Surgery: Defined by the American Society of Plastic Surgeons, "is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem." Functional/Physical Impairment: A physical/functional or physiological impairment causes deviation from the normal function of a tissue or organ. This results in a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities and is exhibited by difficulties in one or more of the following areas:

physical and motor tasks; independent movement; performing basic life functions.

Injury: Bodily damage other than Sickness, including all related conditions and recurrent symptoms.

Microtia: The most complex congenital ear deformity when the outer ear appears as either a sausage-shaped structure resembling little more than the earlobe. It may or may not be missing the external auditory or hearing canal. Hearing is impaired to varying degrees.

Reconstructive Surgery: Defined by the American Society of Plastic Surgeons, "is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.”

Sickness: Physical illness, disease or Pregnancy. The term Sickness as used in this Certificate does not include mental illness or substance abuse, regardless of the cause or origin of the mental illness or substance abuse.

Coding Clarification

** Flaps (Skin and/or Deep Tissues) Procedures: 15570-15738

o The regions listed refer to a donor site when a tube is formed for later transfer or when a "delay" of flap occurs prior to the transfer. Codes 15732-15738 are described by donor site of the muscle, myocutaneous, or fasciocutaneous flap.

o A repair of a donor site requiring a skin graft or local flaps is considered an additional separate procedure.

o (For microvascular flaps, see 15756-15758)

o (For flaps without inclusion of a vascular pedicle, see 15570-15576)

o (For adjacent tissue transfer flaps, see 14000-14302)

o The regions listed refer to the recipient area (not the donor site) when a flap is being attached in a transfer or to a final site.

o Codes 15570-15738 do not include extensive immobilization (e.g., large plaster casts and other immobilizing devices are considered additional separate procedures).

** Other Flaps and Grafts Procedures: 15740-15777

o Neurovascular pedicle procedures are reported with 15750. This code includes not only skin but also a functional motor or sensory nerve(s). The flap serves to reinnervate a damaged portion of the body dependent on touch or movement (e.g., thumb). Repair of donor site requiring skin graft or local flaps should be reported as an additional procedure.

o Code 15740 describes a cutaneous flap, transposed into a nearby but not immediately adjacent defect, with a pedicle that incorporates an anatomically named axial vessel into its design. The flap is typically transferred through a tunnel underneath the skin and sutured into its new position. The donor site is closed directly.

o For random island flaps, V-Y subcutaneous flaps, advancement flaps, and other flaps from adjacent areas without clearly defined anatomically named axial vessels, see 14000-14302.

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