• Ancillary Staff Performing History Component

    Question: An internal auditor said technicians cannot complete the history component. Is the physician required to complete the history of present illness when billing E/M services?

    Answer: The E/M guidelines are based primarily on physician work. When the payer publishes in writing that the physician must personally document the chief complaint and elements of the history of the present illness, you must follow those guidelines. When the payer has provided nothing in writing, however, it is sufficient to have ancillary staff obtain elements of the history and exam; physician review of the staff’s documentation suffices.

    No such payer requirement exists for Eye visit code documentation.

    Note that services at an educational institution have different requirements from private practices, which you must follow.