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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Policies, Procedures, and Documentation 

Standard: Policies and Procedures

Implement reasonable and appropriate policies and procedures to comply with the standards, implementation specifications, or other requirements.  This standard is not to be construed to permit or excuse an action that violates any other standard, implementation specification, or other requirements. A covered entity or business associate may change its policies and procedures at any time, provided that the changes are documented and are implemented in accordance with this subpart.

Standard: Documentation

Maintain the policies and procedures implemented to comply in written (which may be electronic) form; and

If an action, activity or assessment is required to be documented, maintain a written (which may be electronic) record of the action, activity, or assessment.

Time limit (Required)

Retain the documentation for six (6) years from the date of its creation or the date when it last was in effect, whichever is later.

Availability (Required)

Make documentation available to those persons responsible for implementing the procedures to which the documentation pertains.

Updates (Required)

Review documentation periodically, and update as needed, in response to environmental or operational changes affecting the security of the electronic protected health information.


45 C.F.R. ยง164.316

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