SSAs are required to document all contact with an individual, related to service provision, as case notes — even if the activity is not billable.
Whether it’s a phone call, email, meeting, or quick check-in, documentation supports case integrity, accountability, and ensures continuity of care.
Inadequate or missing documentation can put the SSA and agency at legal risk, potentially leading to liability claims such as misfeasance, malfeasance, or nonfeasance.
If the activity is related to the individual, it belongs in the individual’s file.
If you have questions about anything TCM-related, please contact us at TCMTeam@medicaidbillingsolutions.com.
