You now must keep ordering and referring physicians’ documentation for 7 years

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Note:  The following article synopsis was NOT provided by HCPro. It was created by Find-A-Code/innoviHealth.

Article Overview

This article explains a CMS transmittal affecting how providers document and retain ordering and referring records for selected services, including the types of documentation that must be maintained and made available on request. It is relevant to physicians, practices, and coding/billing staff who work with Medicare patients, especially those involved in ordering or performing services such as imaging, lab testing, DME, and home health. The article also notes the compliance concerns that prompted the policy and points readers to related CMS and OIG resources.

Why This Topic Matters

Providers may need to adjust recordkeeping workflows to ensure required order documentation is preserved for the required retention period and can be produced when requested. This matters for compliance, audit readiness, and coordination between ordering and performing entities.

What You Will Learn

  • What documentation retention requirement CMS described
  • Which general service categories are affected
  • Why ordering documentation and provider identifiers matter for compliance
  • What kinds of recordkeeping gaps have raised concern in oversight reviews

Who Should Read This

  • Physicians
  • Medical practice staff
  • Coding and billing professionals
  • Compliance staff
  • Medicare providers

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