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Chapter 1.2 : Procedure Coding, Reimbursement, and Billing Compliance
The Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services issued compliance program guidance for clinical laboratories in August 1998 ( 2 ). This anti-fraud and abuse document addresses Medicare and Medicaid program integrity, with emphasis on issues such as coding and billing; medical necessity; sales and marketing; arrangements with outside providers, suppliers, and vendors; and auditing and monitoring. Every clinical laboratory should be committed to doing business with any client, governmental or private, in an honest and trustworthy manner. While this document covers principles laid out in the federal compliance program guidance, the issues of integrity and the prevention of wrongdoing must be customized for each clinical laboratory to be compatible with the overall institutional compliance program. Specific details pertaining to elements of the Medicare program are detailed in Medicare Laboratory Payment Policy from the Institute of Medicine ( 1 ).