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Combining History with Illness In Your Medical Billing

Combining History with Illness In Your Medical Billing

Combining history of present illness and review of systems is possible when doing medical billing. Many medical billers think this practice is breaking a rule or impossible. However, documenting an element once to account for HPI and ROS is perfectly legal when done correctly. The CMS states that physicians absolutely do not need to document an element two times just so the person performing medical billing knows it is meant to be used both for review of systems and history of present illness. It is perfectly acceptable to use an element for both.

The only time an element cannot be used twice is when you attempt to use it in the same area. For example, the complaint of chest pain cannot be used in ROS for musculoskeletal systems and the cardiovascular system. It can be used only for one location in the medical billing. A medical biller also cannot use a timing phrase such as “began two days ago” to account for both the HPI duration and timing. Direct medical documentation must be used.

The most important thing to accomplish in medical billing is to make the bill match the service. When this occurs, payment is made quicker. Medical billing companies can assist medical practices with this task. Outsourcing your medical billing can be one of the most beneficial things for a practice. This takes the worry off correctly coding and billing for procedures and physicians will see reimbursements much more quickly.

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