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News Flash – On June 18, 2010, the Office of the National
Coordinator for Health Information
Technology (ONC) issued a final rule to establish a temporary
certification program for electronic health
record (EHR) technology. To see the press release related to
this rule, visit
http://www.hhs.gov/news/press/2010pres/06/20100618d.html on
the Internet.
MLN Matters® Number: SE1022 Related Change Request (CR)
#: N/A
Related CR Release Date: N/A Effective Date: N/A
Related CR Transmittal #: N/A Implementation Date: N/A
Medical Record Retention and Media Formats for Medical
Records
Provider Types Affected
This is an informational article for physicians, non-physician
practitioners,
suppliers, and providers submitting claims to Medicare
contractors (carriers, fiscal
intermediaries (FIs), and Medicare Administrative Contractors
(MAC)) for services
provided to Medicare beneficiaries.
Provider Action Needed
STOP – Impact to You
This Special Edition is informational in nature. There are no
additions or changes
to current policies and procedures.
CAUTION – What You Need to Know
This article provides guidance for physicians, suppliers, and
providers on record
retention timeframes.
GO – What You Need to Do
Review the information in this article and ensure that you are in
compliance. Be
sure to inform your staff.
Disclaimer
This article was prepared as a service to the public and is not
intended to grant rights or impose obligations. This article may
contain references or links to statutes, regulations, or other
policy materials. The information provided is only intended to
be a general summary. It is not intended to take the place of
either the written law or regulations. We encourage readers to
review the specific statutes, regulations and other interpretive
materials for a full and accurate statement of their contents.
Page 1 of 3
http://www.hhs.gov/news/press/2010pres/06/20100618d.html
MLN Matters® Number: SE1022 Related Change Request
Number: N/A
Disclaimer
This article was prepared as a service to the public and is not
intended to grant rights or impose obligations. This article may
contain references or links to
statutes, regulations, or other policy materials. The information
provided is only intended to be a general summary. It is not
intended to take the place of either
the written law or regulations. We encourage readers to review
the specific statutes, regulations and other interpretive materials
for a full and accurate statement
of their contents.
Page 2 of 3
Retention Periods
State laws generally govern how long medical records are to be
retained.
However, the Health Insurance Portability and Accountability
Act (HIPAA) of 1996
(HIPAA) administrative simplification rules require a covered
entity, such as a
physician billing Medicare, to retain required documentation for
six years from
the date of its creation or the date when it last was in effect,
whichever is
later. HIPAA requirements preempt State laws if they require
shorter periods.
Your State may require a longer retention period. The HIPAA
requirements are
available at 45 CFR 164.316(b)(2)
(http://ecfr.gpoaccess.gov/cgi/t/text/text-
idx?c=ecfr&tpl=/ecfrbrowse/Title45/45cfr164_main_02.tpl) on
the Internet.
While the HIPAA Privacy Rule does not include medical record
retention
requirements, it does require that covered entities apply
appropriate
administrative, technical, and physical safeguards to protect the
privacy of medical
records and other protected health information (PHI) for
whatever period such
information is maintained by a covered entity, including
through disposal. The
Privacy Rule is available at 45 CFR 164.530(c)
(http://ecfr.gpoaccess.gov/cgi/t/text/text-
idx?c=ecfr&tpl=/ecfrbrowse/Title45/45cfr164_main_02.tpl) on
the Internet.
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]
(http://www.access.gpo.gov/nara/cfr/waisidx_05/42cfr482_05.ht
ml) on the
Internet.
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]
(http://ecfr.gpoaccess.gov/cgi/t/text/text-
idx?c=ecfr;sid=ab240bf0e5f6388a75cbe07cc5cf1d21;rgn=div5;v
iew=text;nod
e=42%3A3.0.1.1.9;idno=42;cc=ecfr) on the Internet.
Providers/suppliers should maintain a medical record for each
Medicare
beneficiary that is their patient. Remember that medical records
must be
accurately written, promptly completed, accessible, properly
filed and retained.
Using a system of author identification and record maintenance
that ensures the
integrity of the authentication and protects the security of all
record entries is a
good practice.
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
http://ecfr.gpoaccess.gov/cgi/t/text/text-
idx?c=ecfr&tpl=/ecfrbrowse/Title45/45cfr164_main_02.tpl
http://ecfr.gpoaccess.gov/cgi/t/text/text-
idx?c=ecfr&tpl=/ecfrbrowse/Title45/45cfr164_main_02.tpl
http://ecfr.gpoaccess.gov/cgi/t/text/text-
idx?c=ecfr&tpl=/ecfrbrowse/Title45/45cfr164_main_02.tpl
http://ecfr.gpoaccess.gov/cgi/t/text/text-
idx?c=ecfr&tpl=/ecfrbrowse/Title45/45cfr164_main_02.tpl
http://www.access.gpo.gov/nara/cfr/waisidx_05/42cfr482_05.ht
ml
http://ecfr.gpoaccess.gov/cgi/t/text/text-
idx?c=ecfr;sid=ab240bf0e5f6388a75cbe07cc5cf1d21;rgn=div5;v
iew=text;node=42%3A3.0.1.1.9;idno=42;cc=ecfr
http://ecfr.gpoaccess.gov/cgi/t/text/text-
idx?c=ecfr;sid=ab240bf0e5f6388a75cbe07cc5cf1d21;rgn=div5;v
iew=text;node=42%3A3.0.1.1.9;idno=42;cc=ecfr
http://ecfr.gpoaccess.gov/cgi/t/text/text-
idx?c=ecfr;sid=ab240bf0e5f6388a75cbe07cc5cf1d21;rgn=div5;v
iew=text;node=42%3A3.0.1.1.9;idno=42;cc=ecfr
MLN Matters® Number: SE1022 Related Change Request
Number: N/A
Page 3 of 3
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.
Providers may want to obtain legal advice concerning record
retention after these
time periods and medical document format.
Additional Information
CMS is currently engaged in a multi-year project to offer
incentives to eligible
providers that meaningfully use certified electronic health
records (EHRs). In
close coordination with this incentive program, the Office of the
National
Coordinator for Health IT (ONC) has developed the initial set
of standards and
certification requirements for EHRs in order to promote health
information
exchange and interoperability. You may be eligible to receive
incentive payments
to assist in implementing certified EHR technology systems.
Use of “certified EHR technology” is a core requirement for
physicians and other
providers who seek to qualify to receive incentive payments
under the Medicare
and Medicaid Electronic Health Record Incentive Programs
provisions authorized
in the Health Information Technology for Economic and
Clinical Health (HITECH)
Act. HITECH was enacted as part of the American Recovery
and Reinvestment
Act (ARRA) of 2009.
Additional information about this initiative may be found at
http://www.cms.gov/EHRIncentivePrograms/ on the CMS
website.
If you have any questions, please contact your carrier, FI or A/B
MAC, at their toll-
free number, which may be found at
http://www.cms.gov/MLNProducts/downloads/CallCenterTollNu
mDirectory.zip on
the CMS website.
Disclaimer
This article was prepared as a service to the public and is not
intended to grant rights or impose obligations. This article may
contain references or links to
statutes, regulations, or other policy materials. The information
provided is only intended to be a general summary. It is not
intended to take the place of either
the written law or regulations. We encourage readers to review
the specific statutes, regulations and other interpretive materials
for a full and accurate statement
of their contents.
http://www.cms.gov/EHRIncentivePrograms/
http://www.cms.gov/MLNProducts/downloads/CallCenterTollNu
mDirectory.zip
Instructions for Chapter 4
PowerPoint Assignment
1. For this assignment you are going to research three (3)
countries for the following:
a. Greeting in a business setting
i. Handshake, etc.
b. Exchange of business cards
c. Gift giving for business
d. Dining out for a business meeting
2. You may use your home country as one of the countries. You
will then chose two other countries.
3. You will develop a PowerPoint presentation that provides a
comparison of these three countries.
a. The information for each topic may be on one or more slide.
b. You will need to put a citation on each slide that the
information is not your own original thought.
i. This may be in small print at the bottom of the slide
c. You are welcome to use graphics on the slides, transitions,
and animation.
i. It is not, however, required.
4. You will have the following slides:
a. Title slide
b. Greetings (may be more than one slide)
c. Exchange of business cards (may be more than one slide)
d. Gift giving (may be more than one slide)
e. Dining out (may be more than one slide)
f. Q & A slide
g. Reference slide
5. If you have any other questions about this project, be sure to
ask.
Professional Practice Activity
As HIT Professionals, you need to understand health record
retention requirements. Many of these requirements are
influenced by internal policy and external regulations. Your
ability to effectively make decisions depends on retention
impact cost, storage space, and compliance. The following
information by the Center for Medicare and Medicaid Services
(CMS) provides guidance and answers to many questions on
health record retention.
For this assignment, go to the attached document. Search for
information and guidance on health record retention
requirements to answer the following questions.
1. Would HIPAA preempt state laws if state laws are more
stringent than HIPAA laws? Briefly explain.
2. It is true that the HIPAA Privacy Rule, 45 CFR 164.530 (c),
it includes all medical record retention requirements you need
to follow? Briefly explain.
3. Where would you find HIPAA administrative simplification
rules for covered entities on retention requirements of health
record documentation?
4. How long does CMS require Medicare managed care
programs providers to retain records?
5. The Medicare program requires that medical records need to
be in what format to be audited?
6. What agency has developed the initial set of standards and
certification for EHRs in order to promote health information
exchange and interoperability?
7. What is a core requirement for physicians and other providers
to qualify to receive incentive payments under "HITECH Act"?
8. What does HITECH stand for?
9. What is the CMS website for information on the EHR
Incentive Program?
As requirements are changing for EHR technology, it is
important that you, as an HIT professional, understand the
requirements and who is responsible for overseeing standards,
implementation specifications, and certification criteria for
EHRs.
10. List two (2) links to websites provided by CMS that provide
additional information to health care providers.

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  • 1. News Flash – On June 18, 2010, the Office of the National Coordinator for Health Information Technology (ONC) issued a final rule to establish a temporary certification program for electronic health record (EHR) technology. To see the press release related to this rule, visit http://www.hhs.gov/news/press/2010pres/06/20100618d.html on the Internet. MLN Matters® Number: SE1022 Related Change Request (CR) #: N/A Related CR Release Date: N/A Effective Date: N/A Related CR Transmittal #: N/A Implementation Date: N/A Medical Record Retention and Media Formats for Medical Records Provider Types Affected This is an informational article for physicians, non-physician practitioners, suppliers, and providers submitting claims to Medicare contractors (carriers, fiscal intermediaries (FIs), and Medicare Administrative Contractors (MAC)) for services provided to Medicare beneficiaries. Provider Action Needed
  • 2. STOP – Impact to You This Special Edition is informational in nature. There are no additions or changes to current policies and procedures. CAUTION – What You Need to Know This article provides guidance for physicians, suppliers, and providers on record retention timeframes. GO – What You Need to Do Review the information in this article and ensure that you are in compliance. Be sure to inform your staff. Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. Page 1 of 3 http://www.hhs.gov/news/press/2010pres/06/20100618d.html MLN Matters® Number: SE1022 Related Change Request Number: N/A Disclaimer
  • 3. This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. Page 2 of 3 Retention Periods State laws generally govern how long medical records are to be retained. However, the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (HIPAA) administrative simplification rules require a covered entity, such as a physician billing Medicare, to retain required documentation for six years from the date of its creation or the date when it last was in effect, whichever is later. HIPAA requirements preempt State laws if they require shorter periods. Your State may require a longer retention period. The HIPAA requirements are available at 45 CFR 164.316(b)(2) (http://ecfr.gpoaccess.gov/cgi/t/text/text- idx?c=ecfr&tpl=/ecfrbrowse/Title45/45cfr164_main_02.tpl) on the Internet. While the HIPAA Privacy Rule does not include medical record retention
  • 4. requirements, it does require that covered entities apply appropriate administrative, technical, and physical safeguards to protect the privacy of medical records and other protected health information (PHI) for whatever period such information is maintained by a covered entity, including through disposal. The Privacy Rule is available at 45 CFR 164.530(c) (http://ecfr.gpoaccess.gov/cgi/t/text/text- idx?c=ecfr&tpl=/ecfrbrowse/Title45/45cfr164_main_02.tpl) on the Internet. 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] (http://www.access.gpo.gov/nara/cfr/waisidx_05/42cfr482_05.ht ml) on the Internet. 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] (http://ecfr.gpoaccess.gov/cgi/t/text/text- idx?c=ecfr;sid=ab240bf0e5f6388a75cbe07cc5cf1d21;rgn=div5;v iew=text;nod e=42%3A3.0.1.1.9;idno=42;cc=ecfr) on the Internet. Providers/suppliers should maintain a medical record for each Medicare beneficiary that is their patient. Remember that medical records
  • 5. must be accurately written, promptly completed, accessible, properly filed and retained. Using a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries is a good practice. 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 http://ecfr.gpoaccess.gov/cgi/t/text/text- idx?c=ecfr&tpl=/ecfrbrowse/Title45/45cfr164_main_02.tpl http://ecfr.gpoaccess.gov/cgi/t/text/text- idx?c=ecfr&tpl=/ecfrbrowse/Title45/45cfr164_main_02.tpl http://ecfr.gpoaccess.gov/cgi/t/text/text- idx?c=ecfr&tpl=/ecfrbrowse/Title45/45cfr164_main_02.tpl http://ecfr.gpoaccess.gov/cgi/t/text/text- idx?c=ecfr&tpl=/ecfrbrowse/Title45/45cfr164_main_02.tpl http://www.access.gpo.gov/nara/cfr/waisidx_05/42cfr482_05.ht ml http://ecfr.gpoaccess.gov/cgi/t/text/text- idx?c=ecfr;sid=ab240bf0e5f6388a75cbe07cc5cf1d21;rgn=div5;v iew=text;node=42%3A3.0.1.1.9;idno=42;cc=ecfr http://ecfr.gpoaccess.gov/cgi/t/text/text- idx?c=ecfr;sid=ab240bf0e5f6388a75cbe07cc5cf1d21;rgn=div5;v iew=text;node=42%3A3.0.1.1.9;idno=42;cc=ecfr http://ecfr.gpoaccess.gov/cgi/t/text/text- idx?c=ecfr;sid=ab240bf0e5f6388a75cbe07cc5cf1d21;rgn=div5;v iew=text;node=42%3A3.0.1.1.9;idno=42;cc=ecfr
  • 6. MLN Matters® Number: SE1022 Related Change Request Number: N/A Page 3 of 3 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. Providers may want to obtain legal advice concerning record retention after these time periods and medical document format. Additional Information CMS is currently engaged in a multi-year project to offer incentives to eligible providers that meaningfully use certified electronic health records (EHRs). In close coordination with this incentive program, the Office of the National Coordinator for Health IT (ONC) has developed the initial set of standards and certification requirements for EHRs in order to promote health information exchange and interoperability. You may be eligible to receive incentive payments to assist in implementing certified EHR technology systems. Use of “certified EHR technology” is a core requirement for physicians and other
  • 7. providers who seek to qualify to receive incentive payments under the Medicare and Medicaid Electronic Health Record Incentive Programs provisions authorized in the Health Information Technology for Economic and Clinical Health (HITECH) Act. HITECH was enacted as part of the American Recovery and Reinvestment Act (ARRA) of 2009. Additional information about this initiative may be found at http://www.cms.gov/EHRIncentivePrograms/ on the CMS website. If you have any questions, please contact your carrier, FI or A/B MAC, at their toll- free number, which may be found at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNu mDirectory.zip on the CMS website. Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. http://www.cms.gov/EHRIncentivePrograms/ http://www.cms.gov/MLNProducts/downloads/CallCenterTollNu mDirectory.zip
  • 8. Instructions for Chapter 4 PowerPoint Assignment 1. For this assignment you are going to research three (3) countries for the following: a. Greeting in a business setting i. Handshake, etc. b. Exchange of business cards c. Gift giving for business d. Dining out for a business meeting 2. You may use your home country as one of the countries. You will then chose two other countries. 3. You will develop a PowerPoint presentation that provides a comparison of these three countries. a. The information for each topic may be on one or more slide. b. You will need to put a citation on each slide that the information is not your own original thought. i. This may be in small print at the bottom of the slide c. You are welcome to use graphics on the slides, transitions, and animation. i. It is not, however, required. 4. You will have the following slides: a. Title slide b. Greetings (may be more than one slide) c. Exchange of business cards (may be more than one slide) d. Gift giving (may be more than one slide) e. Dining out (may be more than one slide) f. Q & A slide g. Reference slide 5. If you have any other questions about this project, be sure to ask. Professional Practice Activity As HIT Professionals, you need to understand health record retention requirements. Many of these requirements are
  • 9. influenced by internal policy and external regulations. Your ability to effectively make decisions depends on retention impact cost, storage space, and compliance. The following information by the Center for Medicare and Medicaid Services (CMS) provides guidance and answers to many questions on health record retention. For this assignment, go to the attached document. Search for information and guidance on health record retention requirements to answer the following questions. 1. Would HIPAA preempt state laws if state laws are more stringent than HIPAA laws? Briefly explain. 2. It is true that the HIPAA Privacy Rule, 45 CFR 164.530 (c), it includes all medical record retention requirements you need to follow? Briefly explain. 3. Where would you find HIPAA administrative simplification rules for covered entities on retention requirements of health record documentation? 4. How long does CMS require Medicare managed care programs providers to retain records? 5. The Medicare program requires that medical records need to be in what format to be audited? 6. What agency has developed the initial set of standards and certification for EHRs in order to promote health information exchange and interoperability? 7. What is a core requirement for physicians and other providers to qualify to receive incentive payments under "HITECH Act"? 8. What does HITECH stand for? 9. What is the CMS website for information on the EHR
  • 10. Incentive Program? As requirements are changing for EHR technology, it is important that you, as an HIT professional, understand the requirements and who is responsible for overseeing standards, implementation specifications, and certification criteria for EHRs. 10. List two (2) links to websites provided by CMS that provide additional information to health care providers.