Wiki MDM data points and obtaining history from someone other than patient

[Skylakes]

We were recently told that it is appropriate to give two MDM data points when a patient has a family member in the treatment room, to provide language interpretation.

We would appreciate other thoughts and opinions on this.

Tara Irvine
HIM Director
Sky Lakes Medical Center

 

[thomas7331]

I would disagree with this. The CMS official guidelines in this section describe this element as 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". In context, this is clearly a different thing from the use of a language interpreter to communicate directly with the patient in that it involves a need for additional information require to diagnose and treat a patient above and beyond was is available directly from the patient themselves. Translating is not the same as providing additional information. In addition, I would also be concered that a practice of using a patient's inability to speak a language as a factor that could potentially increase the amounts charged for a service could be risky from a compliance standpoint and could be seen as a form of discrimination. The laws in most places I've worked require healthcare providers to offer interpreter services at no cost if necessary so it would not be appropriate to factor this into the determination of an E&M level.