Part B Insider - 2021 Issue 3
Reader Questions: Depend on the Answer to This Independent Historian Question
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Article Overview
This reader question and answer article explains a specific point from the 2021 CPT office/outpatient evaluation and management guidelines. It is aimed at coders, auditors, and clinicians who work with E/M documentation and medical decision-making, and it focuses on how the guidelines characterize an independent historian in the context of patient history taking.
Why This Topic Matters
Understanding how the office/outpatient E/M guidelines frame history sources can affect documentation review and the evaluation of medical decision-making. The article helps readers interpret a nuanced guideline concept within CPT® 2021 without needing to rely on assumptions.
What You Will Learn
- How the 2021 CPT office/outpatient E/M guidelines address independent historians
- How a reader question is framed within the context of medical decision-making
- How guideline language relates to history provided by someone other than the patient
- What type of documentation issue the article is clarifying
Who Should Read This
- Medical coders
- Coding auditors
- Physicians
- Urgent care staff
- Clinical documentation specialists
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