July 17, 2014



Is there any statute or regulation that defines what must be in a medical record in New  York State?

Thanks, N


No.  I am unaware of any statutory requirements for documentation necessary in a medical record, except for general acknowledgment by statute that record-keeping is required, and medical records must be maintained for a statutory period (usually 6 years for adults).  Documentation requirements are designated by payors, with Medicare setting the standard for the requirements for medical necessity and beyond. Private payors often have their own documentation polices and procedures, that they may or may not make you aware of, or have available.  

If you are concerned about your documentation, or have not had a chart audit in some time, today's question may be a nice reminder that specialists exist who devote their entire time and attention towards working with practitioners to better their documentation practices to help ensure consistent payment by third party payors.  

If you are looking for a referral to a coding expert, let Jennifer know.  We do recommend Annual reviews.    

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