MLN Fact SheetMedical Record Maintenance & Access Requirements
MLN Fact SheetMedical Record Maintenance & Access Requirements
What’s Changed?
● Added medical record information for teaching physicians and residents (page 4)
● Added reminder for providers about signature requirements (page 7)
Substantive content changes are in dark red.
This fact sheet educates Medicare physicians, non-physician practitioners (NPPs), hospitals, other providers,
and suppliers on current regulations at 42 CFR 424.516(f). It gives information on updated documentation
maintenance and access requirements for billing services to Medicare patients. It also tells you how long to
keep the documentation and who’s responsible for providing access.
Who does the updated regulation impact?
● A Medicare provider or supplier providing covered ordered, certified, referred, or prescribed Medicare
Part A or B services, including laboratory and imaging services, items, or drugs
Example:
123 Medical Supply is a DME supplier providing walkers and wheelchairs that Dr. John Doe ordered for
patients. 123 Medical Supply must maintain and provide access to medical records for DME items Dr.
John Doe ordered.
● A physician or, when permitted, an eligible professional who orders, certifies, refers, or prescribes Part A
or B services, items, or drugs
Example:
Dr. John Doe is a physician who orders DME items for his Medicare patients. Dr. John Doe must
maintain and provide access to the medical records related to the DME items, for example, the order,
associated ofce visit records, if requested, whether the DME supplier retains it or not.
The regulation requires you to maintain medical records for 7 years from the date of service (DOS).
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MLN Fact SheetMedical Record Maintenance & Access Requirements
MLN Fact SheetMedical Record Maintenance & Access Requirements
CMS recognizes you may rely upon an employer or another entity to maintain these records. However, if
you get a medical records request, you’re responsible for providing the medical records to us or 1 of our
Medicare contractors.
Who may request access to these medical records?
We or a Medicare contractor may request access to documentation. The term “access to documentation,”
means you must provide or make available the documentation. You must do this in the manner we or 1 of our
contractors requested.
Example:
WPS, a Medicare contractor, sent Dr. John Doe a request for medical records on all orders for
wheelchairs for Medicare patients with a DOS from November 1 - November 10, 2023. Dr. John Doe
must provide complete copies of medical records, per the specic request from WPS.
What type of documentation must you maintain and provide to us or 1 of our
Medicare contractors?
The documentation includes written and electronic documents relating to:
● Orders
● Certifications
● Referrals
● Prescriptions
● Requests for payments for Part A or B services, items, or drugs
Section 30.5.1.2 of the Medicare Benet Policy Manual, Chapter 7, notes that in cases of home health (HH)
care, the certifying physician’s or allowed practitioner’s facility medical record must contain information that
justies the referral for Medicare HH services for the patient. Such referrals should support the patient’s:
● Need for the skilled service
● Homebound status
You must provide documentation used to support the certication of HH eligibility, upon request, to us, the HH
agency (HHA), or review entities. In turn, the HHA must be able to provide the supporting documentation to us
and our review contractors.
These documents must include the NPI of the physician or, when permitted, other eligible professional who
ordered, certied, referred, or prescribed the Part A or B service, item, or drug.
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Medical Record Maintenance & Access Requirements
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MLN Fact Sheet
MLN4840534 April 2024
Medical Record Maintenance & Access Requirements
Upon our request or a request from our contractor, you must provide all documentation to support the
medical necessity of the Part A or B service, item, or drug ordered, referred, certied, or prescribed.
Such documentation may include, but isn’t limited to, the following:
● Physician orders
● Face-to-face evaluations
● Therapy notes
● Assessment notes
● Correspondence to or from the patient
● Photograph or detailed description of service or both
● Any additional documentation to support the medical necessity of the services, items, or drugs
Remember these documentation maintenance and access guidelines apply to any physician or, when
permitted, any eligible professional who orders, certies, refers, or prescribes Part A or B services, items, or
drugs. For these other eligible professionals, the 7-year timeline and access requirements outlined above still
apply. We require the NPI of such eligible professionals to be part of the required documentation.
What medical records and access guidelines apply for teaching physicians
and residents?
Teaching physicians and residents may document their services in a patient’s medical record. You must sign
and date all documents legibly. These documents can be:
● Dictated and transcribed
● Typed
● Handwritten
● Computer-generated
Residency programs outside of Metropolitan Statistical Areas (MSAs) must document the patient’s medical
record with the teaching physician’s physical or virtual presence, if present through audio-video real-time
technology, including telehealth services. Medical records must note the specic service part performed during
the physician’s presence.
You can use documentation macros if you personally add it in a secured or password-protected system.
These macros may be commands in a computer or dictation application in an electronic medical record
that automatically generates predetermined unedited user text. You must provide enough patient-specic
information to support a medical necessity determination.
Besides the macro information, the note in the electronic medical record must describe the patient-specic
services you provided on that date. It’s insufcient documentation if physicians and residents only use macros.
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Medical Record Maintenance & Access Requirements MLN Fact Sheet
What happens if you don’t maintain required documentation or don’t
provide access?
● You must comply with the document maintenance and access requirements at 42 CFR 424.516(f) to
maintain your Medicare enrollment
● Failure to comply with these requirements may result in the revocation of your Medicare enrollment per
42 CFR 424.535(a)(10)
● If we revoke your enrollment, we bar you from participating in the Medicare Program from the effective
date of the revocation until the end of the re-enrollment bar per 42 CFR 424.535(c)
● We may consider each instance of noncompliance in deciding the length of the re-enrollment bar
● Failure to provide 1 medical record listed in the request letter may constitute a single instance
of noncompliance
Sufcient and Decient Access to Documents Examples
Sufcient Access Decient Access
Providing all documentation requested Providing none of the requested documentation
Providing documentation specic to the orders or
certications, as requested
Providing only a portion of the requested
documentation
Providing documentation for the DOS or billing period
requested
Providing similar documentation that doesn’t
contain the order or certication requested
Providing other documents NOT requested
by us or a Medicare Contractor or not
specically directing attention to the requested
documentation
Example:
A Medicare contractor requests copies of all orders of wheelchairs from an ordering physician for all
patients with DOS from November 1 - November 10, 2022. The ordering physician must provide the
copies, in full, per the specic request. If you can’t provide the copies because you didn’t personally
maintain the records, or only provide part of the record, then you haven’t met the requirement to
maintain this documentation and provide access to it. In such cases, you may be subject to the
revocation basis set forth in 42 CFR 424.535(a)(10).
Medical Record Maintenance & Access Requirements
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Medical Record Maintenance & Access Requirements
MLN4840534 April 2024
What are some best practices for meeting the documentation and maintenance
requirements?
● Providers may add language to their
contracts with employers (W-2 relationship)
or entities paying them for their services
(independent contractor relationship)
regarding access to medical documentation.
You may write the contractual language
in a way that makes sure you’ve access
to the medical records upon our request.
We encourage you to discuss contractual
language with your legal counsel.
● If you’re a hospitalist and your hospital
employer solely maintains the medical
records for your Medicare patients, make
sure the hospital is willing to provide
the necessary documents to respond
to a medical records request. Consider
discussing these requirements with the hospital before performing services there. Claiming that the
hospital isn’t providing you with access to medical documents wouldn’t be a valid excuse. We may elect
to revoke your Medicare enrollment for failing to produce medical documentation after a records request
under 42 CFR 424.535(a)(10).
If you work for a telehealth-based practice group or are in a business relationship with any type of
telehealth entity, the above requirements still apply to you. You must make sure that the group or entity is
willing to provide access to the medical records on your orders for Medicare patients upon our request. The
Medicare Telemedicine Health Care Provider fact sheet has more information on telehealth. See Section
4113 of the Consolidated Appropriations Act of 2023 for the extension of many telehealth provisions.
Certicates of Medical Necessity (CMNs) and DME Information Forms (DIFs)
Information on CMNs and DIFs is available either on the claim or in the medical record. So, providers and
suppliers no longer need to submit these forms for DOS on or after January 1, 2023. See Section 5.5 of the
Medicare Program Integrity Manual, Chapter 5, for more information.
Reminder for Independent Diagnostic Testing Facilities (IDTFs)
You must properly store medical records. If we or our contractors request to see these records, you must
provide them within 2 business days. See Section 10.2.2.4 of the Medicare Program Integrity Manual, Chapter
10 for more information.
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Reminder for Signature Requirements
You must meet Medicare’s signature requirements. Insufcient documentation errors that lead to improper
payments may result from unauthenticated medical records. For example:
● No provider signature
● No supervising signature
● Illegible signatures without a signature log or attestation to identify the signer
● An electronic signature without the electronic record protocol or policy that documents the process for
electronic signatures
Resources:
● Complying with Documentation Requirements for Lab Services
● Complying with Medical Record Documentation Requirements
● Complying with Medicare Signature Requirements
Together we can advance health equity and help eliminate health disparities for all minority and
underserved groups. Find resources and more from the CMS Ofce of Minority Health:
● Health Equity Technical Assistance Program
● Disparities Impact Statement
View the Medicare Learning Network® Content Disclaimer and Department of Health & Human Services Disclosure.
The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S.
Department of Health & Human Services (HHS).
Medical Record Maintenance & Access Requirements MLN Fact Sheet
