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  • Does Lack of Access to Records Warrant Billing Comprehensive Examinations?

    Following a fire in our main office that affected our server, all records and prior imaging are currently unavailable. This requires that all patients need a comprehensive evaluation to determine their treatment course. Is it appropriate to bill all comprehensive evaluations because we do not have access to any records?


    The Centers for Medicare & Medicaid Services’ Emergency Preparedness Rule applies here.
    The rule reads: 
    “… Facilities are required to ensure that patient records are secure and readily 
    available to support continuity of care during an emergency. This requirement does not supersede or take away any requirements found under the provider/supplier’s medical records regulations, but rather, this standard adds to such regulations. These policies and procedures must also be in compliance with the Health Insurance Portability and Accountability Act (HIPAA), Privacy and Security Rules at 45 CFR parts 160 and 164, which protect the privacy and security of individual’s personal health information.”

    The policy would be the same for HIPAA security maintaining access to electronic records in a private practice. Although it may be medically necessary to perform a comprehensive exam in lieu of access to medical records, it would not be appropriate to bill for a higher level of exam. Bill the appropriate level of exam for the service rendered had the records been available.