2021 E/M office visits: How to count appropriate sources, independent historians

Why This Topic Matters

Accurate recognition of outside-source and historian information can affect office visit documentation quality and support correct E/M level selection under CPT 2021 guidance.

Article Sections

1. Overview of outside sources in office E/M coding

   Introduces the article’s focus on counting discussions with outside sources and historian information toward office E/M documentation and medical decision-making.

2. Term review: Appropriate sources

   Defines the general concept of an appropriate source and explains how the article distinguishes this category from other outside informants.

3. Term review: Independent historians

   Reviews the role of independent historians in patient history collection and their relationship to documentation for office visit coding.

4. Definition clarified

   Summarizes clarifying updates from CPT-related corrections about how information may be obtained and documented.

5. Documentation details

   Discusses the importance of documenting who was contacted, how the exchange occurred, and the need for sufficient record detail.

6. Appropriate source or independent historian?

   Presents a staff-facing comparison chart that helps distinguish the two source types for office E/M documentation purposes.