The page below is a sample from the LabCE course Medicare Compliance for Clinical Laboratories. Access the complete course and earn ASCLS P.A.C.E.-approved continuing education credits by subscribing online.

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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.