E/M 2021: Appropriate sources, independent historians contribute to MDM

Why This Topic Matters

Understanding these documentation distinctions helps coding and clinical staff recognize when outside communication may support E/M data review and how to document those exchanges clearly for accurate code assignment.

Article Sections

1. Appropriate sources

   This section distinguishes appropriate sources from other outside informants and describes the general role they can play in patient management discussions under CPT guidance.

2. Independent historians

   This section explains the concept of an independent historian and describes the kinds of situations in which outside historical information may be considered in the record.

3. Definition clarified

   This section summarizes a later clarification in CPT errata about how information may be obtained and documented when an outside historian is involved.

4. Documentation details

   This section addresses documentation clarity, including what practitioners should note in the record and when coders may need additional clarification.