Medical Billing Policy

Objective

To ensure that professional billing accurately reflects the services rendered, and that services rendered are appropriately documented and medically necessary.

Policy

• CUIMC clinicians must use their own billing IDs; they may not use others’ numbers when awaiting receipt of their own billing numbers.
• Services rendered must be appropriate and medically necessary.
• Medical records and related documents must be accurate and must clearly and legibly state what the CUIMC clinician did, the correct date of service and the level of physician presence during all procedures. CUIMC clinicians and billing personnel may not enter false information or ask anyone else to enter false information in medical records or related documents.
• The integrity of the medical records and related documents must be protected. Records may not be backdated. Any amendment or addition of records must be in the form of a signed addendum with the current date (not the date of the earlier record). CUIMC clinicians should use the active voice, rather than the passive voice, wherever appropriate, e.g. “I performed the endoscopy,” rather than the “the endoscopy was performed.”
• Medical record entries must be prompt and made as close to the time of service as practicable.

Office for Billing Compliance
Policy#: 10025
Original Date of Issue: 1996
Revised: 3/22/2023
Reviewed: 3/1/2024