decisionhealth Newsletters, Part B News - 2022 Issue 4 (April)
Information please: Follow 6 tips for independent historians
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Article Overview
This short coding article discusses the use of independent historian information in evaluation and management office visit documentation. It is aimed at coders and practitioners who need to understand what types of outside history sources may be relevant to medical decision-making and how to recognize them in the record. The article covers general documentation considerations, source identification, and the role of non-face-to-face communication, without focusing on a specific procedure code or payer policy.
Why This Topic Matters
Accurate recognition of independent historian information can affect how office visit data are documented and analyzed for medical decision-making. This matters for clinicians and coding staff who need consistent, defensible E/M documentation.
What You Will Learn
- What an independent historian is in the context of E/M documentation
- How independent historian information can relate to medical decision-making
- What types of outside sources may contribute to the visit history
- General documentation considerations for capturing independent historian information
Who Should Read This
- Medical coders
- Physicians
- Advanced practice providers
- Clinical documentation staff
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