tci E/M Coding Alert - 2021 Issue Q1

Reader Questions: Depend on the Answer to This Independent Historian Question

Question: Our urgent care center saw an infant for an upper respiratory infection. Under the 2021 office/outpatient E/M guidelines, can a parent be regarded as an independent historian for an infant patient and, if so, does that fulfill the requirements for category 2 in the data element when calculating the level of medical decision making (MDM)? Illinois Subscriber Answer: In the CPT® 2021 guidelines, a parent is given as one of the examples of an independent historian. The guidelines go on to define an independent historian as “an individual … who provides a history in addition to a...

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