Reader Question: Other Sources May Provide History

Why This Topic Matters

History documentation can affect E/M level selection, so teams need to understand what the record should show when history is partially unobtainable. The article helps readers recognize the difference between general guidance and payer-specific interpretation.

Article Sections

1. Question

   A reader presents a documentation scenario involving an initial inpatient admission and incomplete patient history due to the patient’s condition.

2. Answer

   The response summarizes general documentation expectations and notes that payer policies may differ.

3. Tip

   This section explains that history may sometimes be supported by information obtained from sources other than the patient.

4. Action

   This section cites documentation guidance and describes the need to record why history could not be obtained and what other sources were reviewed.

5. Note

   This section discusses situations in which history may not need to drive code selection and mentions emergency department documentation context.

6. Bottom line

   The closing summary emphasizes documenting efforts to gather history and following the relevant payer’s guidance.