Wiki E/M Risk level - history other than pt

[wrightju1]

I have a NP who works pediatrics and does a wonderful job of documenting if her HPI/ROS is obtained from the patient (15 year old, etc.) or if it is obtained by someone else (Mother states...).
We have a debate in our office on if this should be counted in determining the E/M level in the "Data" are as obtaining history from someone other than the patient. They feel that this should only apply to pts whos medical condition prevents the patient from giving information and it does not pertain to patients who are prevented because of their age.
I disagree. I feel that regardless of WHY the provider can't get the information directly from the patient, it is still second hand information that adds a level of difficulty to their MDM.

Does anyone have documentation and/or sources I can refer to in sorting this out?

 

[Tami_F]

I have a NP who works pediatrics and does a wonderful job of documenting if her HPI/ROS is obtained from the patient (15 year old, etc.) or if it is obtained by someone else (Mother states...).
We have a debate in our office on if this should be counted in determining the E/M level in the "Data" are as obtaining history from someone other than the patient. They feel that this should only apply to pts whos medical condition prevents the patient from giving information and it does not pertain to patients who are prevented because of their age.
I disagree. I feel that regardless of WHY the provider can't get the information directly from the patient, it is still second hand information that adds a level of difficulty to their MDM.

Does anyone have documentation and/or sources I can refer to in sorting this out?

This would count towards the amount and/or complexity of data reviewed, rather than risk, to determine the overall level of MDM.

Parents count as historians. We encourage our providers to document the source of the patient's history, whether from a parent, overnight resident or nurse, medical record, etc. They also document a summarization of the history provided. The rationale is essentially that a history obtained from anyone other than the patient is going to be someone else's interpretation of what the patient is experiencing. Regardless of whether the patient is unable to communicate due to age or medical condition, no one else will be able to provide specific details like the quality or exact location of the patient's symptoms. That requires the provider to do more work to diagnose the issue than they might need to do if the patient were able to appropriately communicate.

Here's what the AAP's Coding for Pediatrics 2018 says:

"In young children, all or part of the history is typically obtained from the parent and/or caregiver. Obtaining additional history should not be confused with summarization in the medical record, which may increase the level of MDM (ie, increased amount and complexity of data)."​

Per CMS:

Documentation Guidelines (DG): 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.
DG: Relevant findings from the review of old records, and/or the receipt of additional history from the family, caretaker or other source to supplement that obtained from the patient 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.​