Credit for discussing history from somone other than patient - in pediatrics

leeannatk

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I'm looking for an opinion on giving credit for documentation of the history obtained from someone other than the patient in a pediatric patient. I am reviewing some notes from a review done by someone else and they gave "credit" in the area of MDM for this.
I disagree since in pediatrics you are going to - by default - get history from someone other than the patient, even if it's a teenager who is doing self care. I feel like it is the nature of pediatrics and it doesn't really involve "extra" work.
Anyone have some thoughts on this. I'm getting pushback from a provider since she was previously told by a review to be sure she documented this and would get the "credit"

This is the same provider that wants credit for review and summary of old records when she reviews and summarizes a glucose log (2 - 3 months of data). I'm inclined to agree on the glucose log but not the history.

Thanks!
Lee Ann CPC, CHA
 
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What I do

Our compliance department has indicated that this CAN be credited in the data points - i.e. getting the history from another source.

HOWEVER ... in practice, I rarely have to rely on this to achieve my MDM level. So it's a moot point.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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