E/M Coding Alert - 2024 Issue 1
Reader Question: Consider Independent Historian When Seeking Px Info
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Article Overview
This short reader question-and-answer article clarifies the medical documentation concept of an independent historian and discusses why a provider might seek information from someone other than the patient. It is aimed at coders and other documentation-focused professionals who need to understand the terminology used in encounter notes and how it differs from interpreter or translator support. The article also touches on general documentation expectations and the role of third-party context in clinical history gathering.
Why This Topic Matters
Understanding this terminology helps coders read provider documentation more accurately and recognize when notes refer to a history source rather than a patient-provided account. It is relevant for documentation review, audit preparation, and correct interpretation of encounter records.
What You Will Learn
- What an independent historian is in the context of clinical documentation
- Why a provider may seek history from someone other than the patient
- How third-party language support differs from an independent historian
- What documentation elements providers should include when noting outside history sources
Who Should Read This
- Medical coders
- Clinical documentation specialists
- Coding auditors
- Physician office staff
- Compliance and billing professionals
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