MLN Product (Revised); Title: Medical Record Maintenance & Access Requirements
This revised Product comprises Subregulatory Guidance for Medicare physicians, nonphysician practitioners, hospitals, other providers, and suppliers; and is based on publically available content within updated regulations at 42 Code of Federal Regulations (CFR) Section 424.516(f), https://www.govinfo.gov/content/pkg/CFR-2019-title42-vol3/pdf/CFR-2019-title42-vol3-part424.pdf#page=61. This product educates these entities and provides them information on updated documentation maintenance and access requirements for billing services to Medicare patients. The regulation requires maintenance of medical records for 7 years from the Date of Service (DOS). CMS or a Medicare contractor may request access to medical records. This product outlines the type of documentation that must be maintained and provided to CMS or one of our Medicare contractors, lists some best practices for meeting the documentation and maintenance requirements, and also that the failure to comply with the requirements may result in the revocation of Medicare enrollment per 42 CFR 424.535(a)(10) at https://www.govinfo.gov/content/pkg/CFR-2019-title42-vol3/pdf/CFR-2019-title42-vol3-part424.pdf#page=70. CMS policy or operation subject matter experts also reviewed/cleared this product. Revisions to this Product include following content update:
• Added medical record information for teaching physicians and residents (page 3)
• Added reminder for providers about signature requirements (page 4)
The previous version of this Product is available to the public and currently posted on the CMS website at: https://www.cms.gov/files/document/medical-record-maintenance-and-access-requirements.pdf
Final
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: April 04, 2024
DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.