E/M Coding Alert - 2021 Issue 2
Reader Questions: Know When to Use ‘Independent Historian’
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Article Overview
This reader Q&A addresses a coding scenario in which a surgeon evaluates an infant and the history is obtained from a parent or guardian. It discusses CPT guidance on the independent historian concept, how that topic relates to MDM data elements, and why the issue matters for office and outpatient E/M coding. The article is aimed at coders, billers, and clinicians who work with CPT evaluation and management documentation.
Why This Topic Matters
Understanding when a parent or guardian may be considered an independent historian can affect how documentation is evaluated for office and outpatient E/M services. The topic is important for professionals applying CPT-based MDM rules in pediatric or otherwise limited-history encounters.
What You Will Learn
- How the independent historian concept appears in CPT E/M guidance
- How history from a parent or guardian can relate to MDM data elements
- Why the topic is relevant to office and outpatient evaluation and management coding
- How pediatric or limited-history encounters may affect coding review
Who Should Read This
- Medical coders
- Coding auditors
- Billers
- Physicians
- Surgeons
- Clinical documentation staff
Codes Discussed
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