Wiki Credit for "obtaining history from someone other than patient"

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Barbara Burgess

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For those of you that audit pediatric providers, do you or do you not give the 2 point credit under Medical Decision Making (amount and/or complexity of data to be reviewed) for "obtaining history from someone other than the patient" when the patient is not old enough to provide an adequate history themselves ?? In a lot of cases, it's given that the patient is not the one providing and of the HPI, ROS or PFSH (non-verbal infant, etc) or patient is very young and can only provide limited info ("my tummy hurts"). If you do give credit, do you do it in all cases, or only in some ?? Or credit only if the provider specifically documents that a parent or caregiver was the source of info ?

Having been a peds nurse in my past life, I tend to want to always give this credit to the provider when the patient is clearly non-verbal, and for older peds patients if anything more than just a basic CC and HPI/ROS is documented. Another auditor here feels like it should only be allowed if the provider themselves personally documents that the history was provided by whoever accompanied the patient, and another auditor not at all because "of course the child can't give the history". :confused:

Would appreciate any/all other thoughts and opinions on this !!

Barbara Burgess, RN, CPC, ACS-EM, PCS
Coding Compliance Nurse Specialist
University of South Alabama
 
I don't give additional MDM credit for that

The guidelines state "A decision to obtain old records or decision to obtain additional history
from the family, caretaker or other source to supplement that obtained
from the patient should be documented." (emphasis by me) In your situations the history from the parents is the only history you have so you aren't really getting additional history.

The fact most of your history is going to come from someone other than the patient in pediatrics is just the nature of the beast in my opinion.

Laura, CPC, CEMC
 
Actually, it is the next documentation guideline following that one that I was mulling over........

"Relevant finding from the review of old records, and/or the receipt of
additional history from the family, caretaker or other source should be
documented. If there is no relevant information beyond that already obtained,that fact should be documented. A notation of "Old records reviewed" or"additional history obtained from family" without elaboration is insufficient."

But, you do have a good point in that the wording is still "additional history".

So, in that case then, if we are talking about a 10 year old who can verbalize a chief compliant that they have had "a stomach ache for 2 days" and "puking", but the parent provides the "additional history" of associated fever or diarrhea or that other family members have had the same symptoms recently, or that the child is drinking well, but not eating, etc, etc would you give the provider credit -- as opposed to a 10 month old patient in which case the parent / caretaker would obviously have to provide ALL of the history ???
 
I still wouldn't give credit. Until they are able to come to the appointment by themselves I expect the parent to give history on them.

Just my opinion,

Laura, CPC, CEMC
 
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