Optometry Coding & Billing Alert

Question: My practice is running out of space for storing our paper records. How long do we actually need to keep them? We're also moving to electronic records and are not sure if there are different record-retention rules for paper versus electronic records. Can you explain record retention rules?

Alaska Subscriber

Answer: Storing billing and medical records -- whether paper or electronic -- safely and for the legally appropriate length of time is important for two reasons. Past records ensure your practice has all necessary information in the event of a lawsuit or payer issue, and they provide historical information to help with current patient care.

The general rule is that you should retain all medical and billing records for about seven years because that is how long the audit process can be in some instances. Many experts suggest mirroring your record-retention policy with whatever the statute of limitations is for suing on a contract is in your state.

Caveat: Even though you'll have easily accessible electronic records, you should still hold on to a copy of all paper records for the appropriate amount of time as indicated by your state's statutes. If you keep all paper records, you may opt to keep copies in a separate storage facility if you don't have a lot of space in your office.

As a bonus, many record-storage facilities will make microfiche copies of your records and store those off-premises to ensure you have copies in two separate, safe locations in case of disasters such as fire or flood.

Minor differences: State rules vary as to how long you should keep a minor's records. You may have to keep a minor patient's records until he reaches legal age. With the ease and accessibility of electronic record keeping, your practice should convert your paper storage to electronic copies. And because CD-ROMs require such little storage space, you may want to keep your electronic records indefinitely.

Electronic tips: Maintaining continual backup of your computer files will ensure a smooth transfer of this information into record storage -- and, even more important, it will guard against data loss due to computer problems.

Just as you should keep a separate copy of your billing records off-site, you should keep computer backups off-site as well. Keeping daily backups of your computer files in your information technology office won't be enough if a disaster afflicts your whole building.

Consult an expert: To make sure your record-retention policy is in line with state rules and hasn't overlooked any necessary components, consider having an attorney or billing consultant review your plan. Check with your state optometric association for more information and advice.

-- Answers to You Be the Expert and Reader Questions reviewed by David Gibson, OD, FAAO, a practicing optometrist in Lubbock, Texas.