Optometry Coding & Billing Alert

Published on Thu Jan 22, 2004 PDF

Question: If the patient asks for a copy of her medical records, are the records from other physicians part of the designated record set (DRS)?
         
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Answer: "Yes, absolutely," says Barry Herrin, an attorney with Smith Moore in Atlanta.
 
According to the HIPAA privacy regulations, although you're not required to amend health information you didn't create, you still have to include those other physicians' records in the DRS because it's information that's being used to assess the patient and provide treatment, he says.
 
Suppose your practice sends samples out to a lab for testing, Herrin says. When that lab faxes back the results of the tests you ordered, those results are going to go straight into the patient's record because you're going to use that information to treat the patient, he says.
 
By that same token, he says, there's no reason why records from another physician's office should be treated any differently.
 
"As long as you're still using the other provider's information to assess, manage, treat or diagnose the patient," it must go into the DRS, Herrin says.