Urology Coding Alert

Question: I sometimes e-mail patient records to consultants or other coders for help on how to code. How can I make sure I'm not committing a HIPAA violation?


Georgia Subscriber
Answer: A simple request for help can land you in plenty of HIPAA hot water. The key is to remove all identifying information from the report before you send it.

Under HIPAA's privacy rule, you must be sure you don't send protected health information (PHI) by removing all individually identifiable health information, including health information that reasonably allows individual identification. In general, HIPAA is based on reasonableness.

Best bet: Only send the portions of the report that describe the clinical procedure and findings and include a confidentiality notice at the end of your e-mail. This guideline applies whether you send the e-mail from an office or from home.

Example: You need help coding a complicated open nephrectomy. Before you send out the report by e-mail, you remove the patient's name and Social Security number. You also remove geographic identifiers, dates, phone, fax, and e-mail information, and medical record and device serial numbers. Then you read through the report before you send it to be sure you can reasonably assume the patient is no longer identifiable.

Option: For extra security, you can send an encrypted e-mail to keep information safe.

Caution: Check your state privacy regulations as well because they differ. For example, in Indiana, you can e-mail PHI only with a written agreement with the patient.