Ophthalmology and Optometry Coding Alert

Question: Our office has converted to digital records and we are thinking of shredding our paper medical records. Are we allowed to do that?

Codify Subscriber

Answer: Your state laws will dictate how long you must hang on to medical records, but no matter where you are, you should plan to retain oldpatient charts for a long time. Keeping your medical records not only helps you comply with state laws, but can protect you if you ever face a malpractice case or other lawsuit. If you have your records, you can defend any actions against you, but without the records you have no defense.

HIPAA regulations dictate that Medicare fee-for-service providers keep the documentation for six years from the date you created it, or six years from when the documentation was last in effect (whichever date is later). CMS requires any provider that submits cost reports to keep patient records for at least five years after the cost report closes, while Medicare managed care providers have to keep the records for ten years, according to MLN’s “Medical Record Retention and Media Format for Medical Records” document.

Remember: Even if you use electronic records, you are still subject to the record retention rules, and Medicare does not dictate that you maintain paper records as paper. “Records can be in the original form or in a legally reproduced form — which may be electronic or digital,” the document states. Therefore, if you have your paper records converted to electronic or digital records, you should still be within the rules, but it’s important to check with your state law and even a health care attorney if the rules in your state are unclear.