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Issue #26 - August 22, 2012

AAPC BillingInsider e-Newsletter

F R O M   T H E   F I E L D

Protect Your Practice - Create a Medical Record Retention Policy
By Deli Parham, CPC

With medical records rapidly moving from paper to electronic and real-time fraud detection by Medicare and private insurers, the question of how long medical records should be retained is a priority.

Medical records are not only crucial to providing quality health care, but they protect providers legally. Just how long medical records should be kept depends upon the type of practice, type of record, its potential use, and specific legal requirements. The retention period may vary in each state; some states do not provide medical records retention requirements.

Here are some tips to assist you to create a medical records retention policy:

1. Know your state laws governing:

  • How long are medical records to be retained? (e.g., in Florida, the retention period is five years).
  • What is the statute of limitations for medical malpractice? (e.g., Florida laws provide that certain medical malpractice lawsuits may be filed up to seven years from the date of the alleged negligent conduct).
  • Disciplinary proceedings by the department of health and/or board of medicine can be filed within six years after the incident occurred, or up to 12 years later where fraud, concealment or intentional misrepresentation prevented discovery of the violation. In Florida, 12 years would be the recommended medical records retention time.

2. Know federal laws.

  • HIPAA retention period is six years from creation date or date when the record was last in effect.

3. Know laws governing minors.

  • Minor patients' medical records are handled differently (e.g., in Florida, they may be kept three years after the minor patient reaches majority).

4. Know what type of records may be kept indefinitely.

Records may be kept indefinitely in any of the following situations:

  • Risky situations, including where there is an undesirable outcome
  • Incompetency, at the time of or after treatment (e.g., Alzheimer disease, brain damage, etc.)
  • When a patient is unhappy with results
  • When a patient threatens or files a lawsuit

This sample policy, and the rules and requirements, should be used as a guide. Modify them to meet your specific needs. Any modifications must meet or exceed state or federal requirements, whichever is most stringent.

G O O D   T I P S

Enroll Before Suffering Rejected Claims

Providers and suppliers who haven't enrolled or revalidated with the Centers for Medicare & Medicaid Services (CMS) face denied Part B, durable medical equipment (DME), and Part A home health claims if they haven't established their enrollment records and are of a specialty eligible to order and refer. CMS is not announcing when denials might begin; but, when announced, providers and suppliers will have 60 days to be ready.

CMS offers online registration and support for registering in the Provider Enrollment, Chain and Ownership System (PECOS) program.

If your practice orders or supplies DME, here are some recommended resources available through CMS.

* Even if your practice frequently or infrequently sees and bills Medicare, it is a good idea to enroll. The fact sheet Medicare Enrollment Guidelines for Ordering/Referring Providers can answer most of the basic questions about who must enroll, what is required, and what incentives are available.

* If your practice doesn't frequently bill for Medicare beneficiaries, the fact sheet The Basics of Medicare Enrollment for Physicians Who Infrequently Receive might be useful.

* Two other helpful resources for billers and their practices are MLN Matters® articles: #SE1221 Phase 2 of Ordering and Referring Requirement and #SE1011 Edits on the Ordering/Referring Providers in Medicare Part B, DME and Part A HHA Claims.

F E A T U R E D   S T O R Y

Know When to Bill for Postoperative Care
By Nancy Clark, CPC, CPC-I

The CPT® Surgical Package definition indicates that for every procedure there are bundled, integral preoperative and postoperative services, including typical postoperative follow-up care. If the postoperative care is not "typical" you may be able to bill for the service.

But, how do you determine what constitutes a typical or unusual postoperative care?

Start by identifying typical care. This includes immediate postoperative care, which incorporates dictating operative notes, talking with family and other physicians, writing orders, and evaluating the patient in the post-anesthesia recovery area. Postoperative pain management by the operating surgeon is included, as are supplies and miscellaneous services, consisting of wound dressing changes, care of the incision site, removal of sutures or staples, tubes or drains, casts and splints, and catheters and intravenous lines. All are considered part of postoperative care.

Certain procedures have explicit postoperative inclusions. As an example, endoscopic procedures include postoperative bleeding control. For abdominal surgeries, common side effects are ileus (the distension of the small bowel) and ceasing of peristalsis (the contractions that move intestinal contents forward). Uncomplicated treatment for these conditions would be included in the surgical package.

Exceptions to the postoperative package include:

  • Visits unrelated to the diagnosis for the surgery, unless the visits occur due to a complication of surgery.
  • Treatment for the underlying condition that is not part of the normal recovery from surgery. Examples are diabetes and hypertension.
  • Diagnostic tests or procedures, including diagnostic radiology (for example, X-rays to ensure a fracture was set properly).
  • A distinct surgical procedure that is not for a complication or reoperation, including staged procedures.
  • Postoperative complications requiring a return to the procedure or operating room (OR), such as postoperative hemorrhage, infections, and debridement. Medicare specifically requires a return to the OR.
  • A more extensive procedure, if the initial procedure does not achieve the required outcome.
  • Critical care not typical of the procedure.
  • Immunosuppressive therapy after organ transplantation.

When in doubt as to what constitutes typical postoperative care, consult the surgical specialty society's website. These sites usually offer articles on specific surgical complications and indicate what are considered normal, expected complications. A comprehensive list of specialty society web sites is available.

One last note: Always remember to use the appropriate CPT® modifier when billing within the postoperative period!

FROM THE FIELD is thoughts and experiences from you the reader. If you have any tips, ideas, case studies, or just anecdotes please submit them to us for future editions.

In This Issue
Protect Your Practice
Suffering Rejected Claims
Billing Postoperative Care

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