Wiki Independent Historian??

[buppkl]

I am in a discussion with my Compliance Department on whether, with an infant patient, can a parent be considered an independent historian when obtaining the HPI and therefore be given 1 data point when scoring the MDM under 2021 guidelines? They say no, but I have not come across anything that states specifically that it cannot. The AMA guidelines give the parent as an example of an IH and goes on to state "due to developmental stage" of the patient. What are others doing regarding this?

 

[lcolborn]

Yes, a parent , guardian, surrogate etc. can provide history for child as long as it is documented who is providing the history . It's not automatic , just because it's a minor , it has to be documented. Another independent historian example is if a patient has dementia, psychologically impaired etc. and only one historian is counted.

 

[Cynthia Hughes]

I am in a discussion with my Compliance Department on whether, with an infant patient, can a parent be considered an independent historian when obtaining the HPI and therefore be given 1 data point when scoring the MDM under 2021 guidelines? They say no, but I have not come across anything that states specifically that it cannot. The AMA guidelines give the parent as an example of an IH and goes on to state "due to developmental stage" of the patient. What are others doing regarding this?

If you have not already seen it, the AMA has answered your question (agreeing with you) in the November issue of CPT Assistant. The independent historian is someone who give history that the patient cannot give either completely or at all. Cindy