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.