Dermatology Coding Alert

Question: We have so many files we're hanging onto for patients who haven't been to our practice in years. Some of the patients are dead. How long are we required to keep these files, and do they need to be kept in our office where we can access them quickly?

Answer: Before you shred patient files, check with federal and state regulations to ensure you've kept the records long enough. Otherwise, you're opening your practice up to compliance headaches and potential problems defending yourself in a lawsuit if you can't provide documentation.

Check State Regulations First

The rules for how long you should keep records for patients who are no longer with your practice for whatever reason vary by state.

Minimum: Hold on to the records for at least six years, which is the federal minimum for records retention after the patient is last seen. However, many states mandate that practices keep records longer than six years. State law has more authority than federal statutes in this case.

Best bet: Check with your state's web site and with your malpractice carrier to get the latest guidelines for your area, says Susan Billock, patient accounts manager for Certified Emergency Medicine Specialists PC in Grand Rapids, Mich. The rule may change based on whether you work for a private physician or a public hospital as well.

Example: For example, physicians in Florida must keep medical records for at least five years after their last contact with the patient. Public hospitals in Florida, however, must keep their medical records at least seven years after the patient has been discharged.

Alter Your Thinking for Minors

Regulations are different for records for underage patients. Practices often have to keep records for minor patients longer than the general state mandate.

Reason: This is because the law requires you to keep the records for a period of time after the patient reaches "adult" status, which could be anywhere from age 18 to 21, depending on the state. Again, checking with state's regulations will let you know if your office is being compliant.

Consider Keeping Records for 10 Years

Good idea: Even if your state requires that you keep records for less than 10 years, you may want to make it your office's policy to keep the records for longer than required. For example, the American Health Information Management Association (AHIMA) recommends practices keep records for a decade after the date the patient was last seen, regardless of the particular state regulation.

"I have had many patients call me years after their service was rendered wanting to know what they were seen for and such. Most of these cases are patients that are in collections and are disputing the validity of the claim," Billock says. "It is also a protection for providers against law suits if they can go back and refer to older medical records."

Billing companies: If you are a billing company, consult your attorney about how long you're responsible for compliant data entry of the charges and payments you're reporting for practices, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. "This is the only proof that you're only entering what the doctor gave you, and if you get rid of it early because the state says you can, you no longer have proof that you were not taking liberties that you were not allowed to take."

Save Space in the Office

You don't have to find space to keep inactive patient records in your office for 10 years. Storing files in a separate storage area frees up space in your office, while still ensuring that you can access hard copies of patient records if need be.
 
"Before we went to scanning, we only kept the current year's charts and the previous year in office. The rest went to a medical record storage place," Billock says.

Go electronic: Since electronic record-keeping and storage is fairly easy and accessible now, consider moving paper storage to electronic copies of all records relating to patients' care and treatment. And because CD-ROMs require such little storage space, you could keep your electronic records indefinitely.

Caution: If you move to an electronic form of storage, even though you'll have easily accessible electronic records, you should still hold onto a copy of all paper billing records for the appropriate amount of time as indicated by your state's statutes.