Q: How long should we keep charge tickets in the ambulatory care setting? Currently in our hospital based clinics, the physician completes a charge ticket and checks off procedures as well as an E&M. The original is sent to the physician’s practice for billing, and the copy stays with the hospital for the billing clerk to enter charges and choose the correct level for the facility reimbursement. We have been told these should be kept for seven years for auditing purposes, but this is an administrative tool and not the source document that would be the medical record, even though the physician’s selection of an E&M is not documented in the medical record.
A: The rule for retention of administrative and financial records is seven years. A provider should adhere to its medical records and medical staff bylaws for guidance on retention of medical records, whether paper or electronic.
David Hammer answered this question
