Documentation Integrity and Compliance Programs

Documentation supports the claim

Codes and charges should be supported by the clinical and administrative record required for the service. Billing staff should not create clinical documentation or change the substance of a record to make a claim payable.

Compliance program building blocks

OIG's healthcare compliance guidance describes seven elements that organizations can use as a framework: written policies and procedures; compliance leadership and oversight; training and education; effective lines of communication; enforcement of standards; auditing and monitoring; and responding to detected problems with corrective action.

What billing staff contribute

• Follow written billing and coding procedures.
• Complete assigned compliance training.
• Document payer follow-up accurately.
• Report recurring denial or coding patterns.
• Cooperate with audits and provide requested records through approved channels.
• Correct identified errors using approved workflows.

Do not “repair” documentation improperly

If documentation is incomplete, follow the organization's compliant query or addendum process. Do not backdate, fabricate, copy-forward unsupported facts or pressure clinicians to document solely for reimbursement.

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