The Centers for Medicare & Medicaid Services leaves certain medical billing policies and office practices hazy in their guidelines. It is common knowledge in the medical billing world that a physician or non physician practitioner must perform the history of present illness portion of an evaluation and management exam. However, this medical billing rule is nowhere to be found in the CMS guidelines.

After examining the Center for Medicare & Medicaid's guidelines, many people wonder if the history of present illness can be taken by an ancillary staff member instead of a physician. Nowhere in the documentation does it prohibit this to be done. Most medical billing policies are spelled out exactly how they should be accomplished. This is an exception to that rule.

The Centers for Medicare & Medicaid Services state in the medical billing guidelines that the family and social history (PFSH) and the review of systems (ROS) can be completed by an ancillary staff member. There is absolutely no mention of these ancillary staff members being allowed to take the history of present illness portion. This omission in the medical billing guidelines has led to the restriction. The only way the ancillary staff member can take any information during the evaluation and management is if the guidelines specifically state so.

Clarifying hazy medical billing information is not the job of your staff members. Your personnel should be free to openly communicate with your patients. Superb customer service should be your main goal. To eliminate all your medical billing responsibilities, a medical billing firm can assist. They can accurately code and submit claims for your practice. They can also follow up on unpaid, or incorrectly paid claims. Medical billing is made simple when you outsource your work. Medical billing firms can do the dirty work for you.