Add appropriate sources and independent historians to your MDM calculations

Why This Topic Matters

Correctly recognizing outside-source discussions and independent historian information can affect whether documentation supports the intended level of office visit coding and helps ensure records are complete and defensible.

Article Sections

1. 2021 E/M office visits

   Introduces the article’s focus on office visit E/M documentation for 2021 and the role of outside-source communication in medical decision-making data review.

2. Term review: Appropriate sources

   Defines the general concept of appropriate sources and explains the kinds of external individuals discussed in the article. It also addresses the timing and direct-communication aspects referenced in the update.

3. Term review: Independent historians

   Discusses the general concept of independent historians and how their information relates to patient history collection and assessment. It also distinguishes this concept from other people who may be involved in communication with the practitioner.

4. Definition clarified

   Summarizes a clarification from the CPT 2021 errata regarding how information may be obtained from an independent historian and the expectation of direct communication.

5. Documentation details

   Covers the documentation emphasis described in the article, including how practitioners should record outside discussions and what details help support coding review.

6. Resource

   Lists the referenced supporting resource used by the article.