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On February 18,we posted an article about what to do with paper medical records when converting to an electronic health record EHR. We decided to re-review the topic, update it, and repost it.
Actually, not much has changed in the way of the law applicable to this topic.
So, the article below reiterates most of the tips from our original article with a few refinements, including additional information about retention periods. Many hospitals have electronic health records EHRs that are hybrid digital records.
While the hospital may be using electronic data entry in the emergency department, inpatient nursing care, pharmacy, lab, and pre-op anesthesia, oftentimes, these EHRs are not integrated and, thus, are not merged into a single EHR.
If the hospital has been maintaining certain portions of patient records in a paper format, what does it do with those paper records after converting to an EHR? If the hospital scans all the paper patient records into its EHR, how long should the hospital retain the paper record after it is scanned into their EHR?
Currently, there is little specific guidance speaking to retention of paper records subsequent to EHR conversion. In other words, once paper records are scanned, they are, in fact, being retained on electronic storage media. Given that the broadening EHR world is in its infancy, retention of paper records for a sufficient period of time is likely the Medical billing research paper course of action in either scenario.
What follows are some of the factors to consider when deciding whether and how long to keep paper medical records. As an initial matter, review your malpractice insurance and seek guidance as to the expectations of your insurer with regard to record retention. Some carriers have actually issued direct policy-requirement statements covering record retention in the context of EHR conversion.
Your carrier may have a requirement or other guidance that would be useful in formulating or revising your record retention policy. Another important consideration is to determine the appropriate malpractice or negligence statute of limitations under applicable state law.
For example, in Kentucky, under KRS This is lengthened to up to two 2 years in the case of wrongful death. See discussion below under Destruction of Evidence. Review the licensing and Medicaid regulations applicable to your organization.
And, speak to your state licensing agency to get their take on how long to keep paper records that have been either scanned to PDF or entered into the EHR in a coded format.
How to work on Medicare insurance denial code, find the reason and how to appeal the claim. Medical billing denial and claim adjustment reason code. Online medical billing and coding degrees prepare students to play a critical role in the management of clinical billing procedures. Coding specialists translate patients' medical records into standardized codes, which are then processed and sent to insurance companies by billing specialists. Providers can purchase software from a vendor, contract with a billing service or clearinghouse that will provide software or programming support, or use HIPAA compliant free billing software that is supplied by Medicare carriers, DMEMACs and A/B MACs.
Individuals within the Kentucky OIG, for example, have indicated that as long as the records can be accessed and accurately produced, there is no requirement to retain the paper versions. It is essential to weigh the regulatory authority viewpoint against the risk of exposure to a spoliation claim.
Federal Law and Medicare. Section b 2 provides that in no event may such an action be brought more than ten 10 years after the date on which the violation is committed.
The Medicare program does not have requirements for the media formats for medical records. However, the medical record needs to be in its original form or in a legally reproduced form, which may be electronic, so that medical records may be reviewed and audited by authorized entities.
Providers must have a medical record system that ensures that the record may be accessed and retrieved promptly. Providers may want to obtain legal advice concerning record retention after these time periods and medical document format.
This MLN also notes the retention period for cost reports is 5 years and the retention period for managed care program provider records is 10 years and many managed care providers require health care providers to retain medical records for up to ten years in the managed care contracts so these documents should also be reviewed when developing your retention policy.
Consider also whether FDA regulations applicable to any research conducted in your facilities, or the U.
Only then can the paper records be destroyed. Accordingly, quality control becomes extremely important when scanning paper documents onto electronic storage media.
Records should only be destroyed in compliance with an established, written internal policy.
There is no single answer for how long to keep the original paper medical records. However, if you have notice of possible litigation or a fraud enforcement action, then it would be prudent to retain the paper versions. Even in the absence of litigation or an impending federal enforcement action, you may decide to retain the paper records for the minimum of the applicable limitation period for a malpractice action, the five-year period indicated by Medicare, or as long as the ten-year False Claims Act statute of limitations.
At a minimum, have a written retention policy that contains quality control procedures and that ensures paper records are not destroyed before their scheduled backup to an identical image.How to Start Medical Billing How to Start a Medical Billing Business A Research Paper For: Medical Billing Mr.
Edgar Raule Prepared by Osary Rodriguez MO1 September 5, This has been a successful business for me in the first year I did not make a lot of money but I did not loss any money at all. Below is an essay on "Medical Billing and Coding" from Anti Essays, your source for research papers, essays, and term paper examples.
Medical Billing and Coding Each time a patient receives medical care, the physician or other health professional must document the services that are provided/5(1).
NOTE: On February 18, , we posted an article about what to do with paper medical records when converting to an electronic health record (EHR). To date, this has been the most popular article on the HITECH Law Blog. We decided to re-review the topic, update it, . Medical billing and coding are two closely related aspects of the modern health care industry.
Both practices are involved in the immensely important reimbursement cycle, which ensures that health care providers are paid for the services they perform. The regulations streamline paper billing by standardizing billing forms and make it easier to communicate through the use of standardized bill review messages.
Provisions relating to standardized paper billing became effective Oct. 15, , and have been updated several times since adoption.
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