Must A Pediatrician Take A Patient’s History?

Must A Pediatrician Take A Patient’s History?

When running a pediatric office there are many questions that come into play with medical billing. It may seem simple for any personnel to ask a few questions and take a patient’s history, but medical billing regulations may actually dictate who is allowed.

In all actuality, it is safe practice to allow any office member to take the review of systems and the family social history. These two evaluation and management history elements can actually be taken by absolutely anyone. It is ok in medical billing for a parent or a secretary to take down this information. The only requirement is that it is recorded and then later reviewed by the pediatrician. Medical billing personnel should make sure the proper documentation is provided before sending a claim onto an insurance company.

The only part of an evaluation and management visit that the physician or nurse practitioner must complete for medical billing purposes is the history of present illness.

Allowing secretarial staff to complete some of the patient documentation can save your practice time and money. This leaves the pediatricians and nurse practitioners available to take in more patients because they don’t have to spend so much time recording answers to questions.

Another way to save your practice time and money is to outsource your medical billing. Medical billing requires a lot of skill and time. Many times office personnel don’t have time to work on a personal level with the customers because they are too busy dealing with medical billing. A way to save time and money is to outsource your medical billing to a medical billing firm.

There are several methods to save your practice money right off the bat. One way is to leave the review of systems up to secretarial personnel. The largest way to save your practice money is to outsource your medical billing responsibilities.

View all Articles by: Melissa Clark, CCS-P