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.