D9961 Duplicate/Copy Patient’s Records

The patient owns their records and therefore is entitled to a copy (not original) whether they have a balance on their account or not. Most practices have digital radiographs, photos, and notes, so it isn’t an access issue.  Providing a copy to the patient or getting permission from the patient to send a copy to their new provider has been a shared and standard operation in dental practices for decades. 

 In 2019 a new code D9961 allowed for the documentation of the transfer of the patient’s records.  The code also provides for a reasonable fee charged to the patient or their insurance carrier.  The code may or may not be a covered benefit depending on the policy.  It should be a standard billing because it requires administrative time and must follow HIPAA security protocol.  The use of the code to refer patients to specialists such as an endodontist or oral surgeon helps track the patient’s treatment progress. The patient record will either be sent via a secure email, placed on a disc or flash drive, or manually copied to paper.  No matter the type of transfer, the patient must provide written permission to release the records to the entity that has requested them.   Depending upon the size of the file and time involved dictates the fee for duplication.  Usually, the cost is 25.00 to 75.00. 

If the practice decides not to charge patients, they should still document the transfer with the code D9961 to ensure a legal record of transfer that includes the entity’s name and contact information, the reason for the request, and the complete list of documents copied and sent.