EM Coding Alert

Question: Our specialty practice sometimes sees pediatric patients, and often a parent/guardian provides a lot of the information pertinent to the presenting problem. I want to make sure the independent historian’s contribution goes toward evaluation and management (E/M) leveling. How can I educate providers on documentation of independent historian contributions so I can count it toward the E/M?

Alabama Subscriber

Answer: Having a parent/guardian provide information during an encounter with a pediatric patient is extremely common, and in many cases the parent qualifies as an independent historian.

The AMA defines an independent historian as “… an individual (eg, parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (eg, due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary.”

The provider doesn’t need to name the independent historian specifically in the documentation, such as “Male patient, 3 years old, presents for concerns about enlarged adenoid tissue. Mary Thompson said he snores regularly and doesn’t seem rested in the morning.” But the provider should document the relationship between the patient and the independent historian.

So, in this situation, if Mary Thompson is the mom — the relationship should be confirmed and not assumed — the provider could write “Mom said patient …” and such a descriptor of the relationship would provide the documentation necessary to count the independent historian while figuring out the correct E/M level.

Remember, the contribution of the independent historian should be medically necessary, and the patient being a minor is not, in and of itself, enough: The AMA references “developmental stage” rather than age in its definition of independent historian.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC