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

Learn more about Medicare Compliance for Healthcare Personnel (online CE course) »
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Documentation of compliance activities is the responsibility of all employees.
  • All forms must be completed and properly filed.
  • All procedures must be followed and properly documented.
  • If documentation of compliance activities cannot be established during an audit or investigation, the government will assume that the compliance program is not being followed.
  • If it cannot be established that the compliance program is being followed due to lack of documentation, CMS will issue compliance letters, such as notices of non-compliance, warning letters, and Corrective Action Plan requests.
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.