Part B Insider - 2016 Issue 11
Reader Question: Clear Up the Confusion Regarding Using an Interpreter in an E/M Visit
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Article Overview
This article addresses a reader question about evaluation and management (E/M) coding when a patient needs an interpreter during an office visit. It discusses CMS documentation guidance, the role of additional history sources in medical decision making, and the general circumstances in which time-based coding may be considered. The piece is aimed at coders and clinicians who document E/M services and need to understand how language interpretation fits into coding review.
Why This Topic Matters
Interpreter use is common in E/M encounters, and misunderstandings about its impact can affect documentation quality and coding accuracy. The article helps readers distinguish between translated patient communication and separately obtained history for coding purposes.
What You Will Learn
- How interpreter use is discussed in the context of E/M documentation
- How CMS guidance relates to obtaining history from sources other than the patient
- Why language translation is treated differently from additional history in MDM context
- When time-based coding may be worth considering in an interpreter-supported visit
Who Should Read This
- Medical coders
- Coding auditors
- Physicians and other E/M providers
- Clinical documentation staff
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