Billing: Documentation

Communication with physicians and patients

  • It is important that billing department employees are clear and accurate when communicating with physician office personnel and patients.
    • Never guess at the answer to a question; ask if you are unsure.
    • Do not speculate or express personal opinions.
  • When requesting diagnosis information from the physician office staff be careful to not lead them to give a billable code:
    • The code must come from the patient's medical record.
  • There is an incentive program for patients to find and report fraud and abuse by health care providers, including laboratories, so:
    • Billing department employees must accurately state laboratory policies and procedures, or forward the call to a supervisor to avoid misstatements and misunderstandings.

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