Anesthesia Coding Alert

Question: How far back can payers go when requesting medical records for review?

Oklahoma Subscriber

Answer: For Medicare, the answer to your question has been 12 months -- until recently.

Effective June 26, 2012, a new policy regarding "look backs" went into effect. Under the old guidelines, a Medicare Administrative Contractor (MAC) could collect documentation "related to the beneficiary's condition before and after a service but shall not request documentation dating from more than 12 months prior to the date of service unless an exception exists," according to Section 3.2.3.4 of the Medicare Program Integrity Manual.

The change: In Transmittal 422 (which went into effect June 26), CMS stated it would do away with that 12-month look-back period. The Transmittal did not specify that CMS was replacing the 12-month look-back period with a new time frame (or if any deadline would be introduced later to replace the previous limit). Therefore, the Manual implies that records can be requested indefinitely from the date of service.

The reality is that your practice most likely retains medical records for much longer than one year anyway, since state statutes of limitation dictate how long you must retain them. In New York, for example, even if a patient leaves your practice you must keep his records for six years after the last visit, whereas in Michigan the records must be kept for seven years. Because of this, the potentially open-ended look-back period shouldn't be an issue of concern for most physician groups.