Cracking the Code

Coding Independent Historians

To appropriately determine the level of visit, MDM is selected based on three components. These are the number and complexity of problems addressed, the amount and/or complexity of data to be reviewed and analyzed, and the risk of complications and/or morbidity or mortality of patient management. The amount and complexity of data for review is measured by the need to order and review tests, and the need to gather information and data. Planning, scheduling, and performing clinical labs and tests from the medicine and radiology portions of CPT are indications of complexity, as is the need to request old records or to obtain additional history from someone other than the patient (such as a family member, caregiver, teacher, etc.). Translation services do not qualify as an independent historian. Documented discussions with the performing physician about unusual or unexpected patient results also may result in credit.

As per AMA, the definition of an independent historian is, an individual (e.g., parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (e.g., due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary. In the case where there may be conflict or poor communication between multiple historians and more than one historian is needed, the independent historian requirement is met. It does not include translation services. The independent history does not need to be obtained in person but does need to be obtained directly from the historian providing the independent information.

What if the patient is a newborn or child that cannot communicate on their own? Does the independent historian still come into play? This question has been asked on many occasions and we have a clear answer. The answer is yes! According to a CPT Assistant from March 2021, volume 31, issue 3, page 9, “a parent or caregiver may be considered an independent historian.” The independent historian should be documented, as we should not assume. It is also important to note that the CPT assist also states that, “an adult who accompanies an elderly parent, who may have a cognitive condition, could also serve as an independent historian.”

Q: “A 6-month-old female patient presents to the ED. Mother states that the child has been pulling at her ears for the past 2 days. Mother also states patient has been experiencing a cough on and off through-out the day.” Does this documentation support an independent historian?
A: Yes. The documentation clearly states that it is the mother that is providing the information and she can be considered the independent historian.
Reference: FY 2023 AMA CPT Evaluation and Management Code and Guidelines, CPT Assistant
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