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Documentation
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The page below is a sample from the LabCE course
Medicare Compliance for Clinical Laboratories (retired)
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Learn more about Medicare Compliance for Clinical Laboratories (retired) (online CE course)
Documentation
All information related to diagnosis or other billing information received from a physician office must be documented.
Documentation includes the name of the person collecting the information, the name of the person giving the information, and the date.
This documentation must be linked to the original order.
Billing department employees must ensure that complete records and documentation exist for all billing transactions.
Not documented means not done.
All communication, (either written or verbal), with government, Carrier, or Fiscal Intermediary representatives must be documented.
Employees should report instances where records are missing, incomplete, or improperly filed, to ensure that corrective action is taken.
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