The Missouri Medicaid Audit and Compliance Unit (MMAC) has received questions from providers whose agencies provide certain types of services under the Department of Mental Health DD Waiver program.  Specifically, providers of day habilitation services have requested clarification regarding adequate documentation as it pertains to participants’ progress notes.

Missouri regulation states adequate documentation is “documentation from which services rendered and the amount of reimbursement received by a provider can be readily discerned and verified with reasonable certainty.”  The regulation states adequate documentation includes “The MO HealthNet participant’s progress toward the goals stated in the treatment plan (progress notes).”

To read the regulation (13 CSR 70-3.030) click here.

MMAC auditors should be able to discern the participant, caregiver, types of services provided, date of service, and length of service, from the progress notes.  The progress notes should articulate the participant’s progress toward the goals in his or her treatment plan.  MMAC auditors will review these documents, along with others, to determine that services were billed for the correct participant on the correct date of service, for the correct amount of time.  They will review the notes to ensure they contain information about the participant’s progress toward the treatment plan goals.

On December 2, 2015, the Department of Mental Health issued a bulletin regarding this subject.  Click here to read the bulletin.   This bulletin provides additional guidance regarding best practices in progress note documentation.

MMAC is committed to working together with Medicaid providers and the Department of Mental Health, regarding continuing clarification on these matters.  If you have any questions, please contact us at MMAC.Providerreview.dss.mo.gov