“Medical Records Retention” Issues Continue to be Important for CMHCs

(August 17, 2010): The Centers for Medicare and Medicaid Services (CMS) recently issued MLM Matters SE1022, titled “Medical Record Retention and Media Formats for Medical Records” which serves as a helpful reminder regarding a number of medical records retention issues faced by Community Mental Health Centers (CMHCs) around the country.  As reflected in the guidance, MLM Matters SE1022 directly applies to health care providers (such as CMHCs) submitting claims to Medicare contractors for services provided to Medicare beneficiaries.

 While medical record retention requirements are generally governed by State law and can vary from State to State, it is important to remember that under HIPAA’s administrative simplification rules,  “covered entities” such as CMHCs,  must retain required medical records for a period of “six years from the date of its creation or the date when it last was in effect, whichever is later.”  As CMHC providers can readily attest, this requirement can be quite difficult to apply when the care as issue involve partial hospitalization program services.  For example, the supporting documentation covering partial hospitalization services provided during a specific period may relate back, and be supported by, a Psychiatric Evaluation, Physician Orders, Hospital Discharge Orders and other documents that were have been created many months prior to the specific dates at issue.  As a result, strict adherance to the six year requirement (assuming that the State retention requirements are six years are less since  HIPAA requirements preempt State laws if the State laws require a shorter medical records retention period) could make it difficult to fully support partial hospitalization claims if an audit is conducted.    Having said that, there are opposing compliance reasons to properly cull outdated medical records when possible.  Finding an acceptable balance between these goals is often difficult and should involve the advise of your legal counsel.

As MLM Matters SE1022 further notes:

 The Centers for Medicare & Medicaid Services (CMS) requires records of providers submitting cost reports to be retained in their original or legally reproduced form for a period of at least 5 years after the closure of the cost report. This requirement is available at 42 CFR 482.24[b][1].

 CMS requires Medicare managed care program providers to retain records for 10 years. This requirement is available at 42 CFR 422.504 [d][2][iii].

 Finally, the guidance points out that the Medicare program:

“. . . does not have requirements for the media formats for medical records. However, the medical record needs to be in its original form or in a legally reproduced form, which may be electronic, so that medical records may be reviewed and audited by authorized entities. Providers must have a medical record system that ensures that the record may be accessed and retrieved promptly.”

 The issue of “records retention” can be quite complex, especially when dealing with partial hospitalization claims.  This issue is further complicated if the CMHC is being audited or under investigation by the government or a Medicare contractor.  In such a situation, we typically advise clients to curtail all document (paper and electronic) destruction activities are until the external review is resolved.  In light of these considerations, it is strongly recommended that you work with your legal counsel to better ensure that your CMHC is meeting its document retention obligations. 

 Should you have questions regarding these issues, you may call your current counsel or you may call Liles Parker for a complimentary consultation at 1 (800) 475-1906.