In order to provide a sanitary, comfortable experience, participating physicians, other health care professionals, facilities and agree to adhere to the following site standards. Offices will be regularly reviewed to ensure compliance with these standards.

Physical accessibility

  • Exterior is generally accessible; the office is easy to locate, parking is available, clearly identified and handicap accessible
  • Interior is generally accessible; is handicap accessible, rooms are clearly identified and office hours are communicated clearly

Physical appearance and safety

Exterior

  • Building is generally clean and well-maintained
  • Exterior premises are safe

Interior

  • Interior is generally clean and well-maintained
  • Interior premises are safe
  • Fire extinguish system is available
  • There is adequate hazardous product disposal
  • Narcotics are securely locked

Waiting room adequacy

  • There are educational materials available
  • The waiting room is generally clean with adequate seating for the number of providers in the office

Examination room adequacy

  • The patient's privacy is protected
  • There is an exam table in each room
  • There is educational information available
  • There is hand washing available in each room
  • The rooms are generally clean and of adequate size
  • There is an assistant available as needed

Appropriate equipment available

  • There are Sharps containers
  • There is resuscitation equipment or Cardiopulmonary Resuscitation (CPR)-certified staff
  • If in-office X-rays performed, state certification has been obtained
  • If in-office laboratory work performed, Clinical Laboratory Improvement Amendments (CLIA) certification has been obtained
  • There are examination instruments – for primary care physicians this would include:
    • Stethoscope
    • Blood pressure cuff
    • Otoscope
    • Ophthalmoscope

Adequacy of medical record keeping

Physicians, other health care professionals and facilities must establish the following policies and procedures:

  • Confidentiality policy
  • Release of information policy
  • Medical records must be readily available
  • Medical records must be kept from public access
  • The patient charts must be organized and contents secured
  • Procedures for assessing and improving content, legibility, organization and completeness of medical records

In addition, providers must maintain a medical record-keeping system that:

  • Permits encounter claim review
  • Conforms to professional medical standards
  • Permits an internal and external medical audit
  • Facilitates an adequate system for follow-up treatment

All medical records must be maintained for at least ten years after the date of medical services.

Medical records must contain all the necessary documentation to support the services rendered and billed, as well as the medical necessity of those services. Valid Current Procedural Terminology (CPT®) codes,  International Classification of Diseases (ICD) codes and Diagnostic and Statistical Manual of Mental Disorders (DSM) codes must be supported by the patient's medical record. If the appropriate documentation is not included, we may be unable to confirm that payment was made appropriately, which can result in requests for refunds from providers. 

Providers must include, at a minimum, the following in medical records:

  • Specific and clear treatment plans
  • Information on advance directives
  • Complete, accurate and legible documentation
  • Complete history, examination and medical decisions
  • Identification of all providers participating in the patient's care
  • Diagnostic testing, laboratory tests and radiology reports and results
  • Prescribed medications, including dosages and dates of initial or refill prescriptions
  • Complete descriptions of the patient's concerns and reason for seeking medical care
  • A problem list, including significant illnesses and medical and psychological conditions
  • Evaluation and assessment of the provider's findings and a complete list of all diagnoses
  • Information on allergies and adverse reactions or a notation that the patient has no allergies or history of adverse reactions

Each entry or page in the medical record must include:

  • Progress notes, any improvement in the patient's condition, changes in the treatment plan and updates to the diagnosis
  • Each page must include the patient's name, date of birth and date of service to verify who the patient is and what date services were provided
  • Each entry must have the rendering provider's signature at the completion of the chart note, medical records, operative report or any other medical document in a patient's file. If an entry spans multiple pages, the signature is required at the end of the entry, but the patient identifiers still need to be on each page.