MDM review of old records and or obtain history other than patient.

[LHighcove]

I was recently told that if a parent of a young child / baby gives information regarding childs symptoms that can be scored as 2 points in MDM as receiving additional information other than patient. Is that accurate? Example.... mom states vomiting and fever for 24 hrs.

 

[Tami_F]

Yes, it's two points. This table shows the data review portion of determining the MDM. It's from the AAPC's E/M training course.

 

[thelton]

I work with a pediatric group. We do not give credit for obtaining history from someone other than the patient when the patient is an infant/young child.....it is a "given" that the parent/guardian will be giving the history. One of our pediatricians even gave us an article a few years ago from a meeting he attended that said it would not be appropriate to give credit for obtaining history for someone other than the patient for infants/young children and all of our pediatricians are in total agreement with this.

 

[mhstrauss]

I work with a pediatric group. We do not give credit for obtaining history from someone other than the patient when the patient is an infant/young child.....it is a "given" that the parent/guardian will be giving the history. One of our pediatricians even gave us an article a few years ago from a meeting he attended that said it would not be appropriate to give credit for obtaining history for someone other than the patient for infants/young children and all of our pediatricians are in total agreement with this.

I agree with this, and remember reading the same thing. I don't work in pediatrics, so I didn't keep the article as a reference, but if I find it again, I'll share link here.

 

[Tami_F]

Interesting. I code pro-fee for a physician group of pediatricians at a children's hospital. Our company policy is to give two points when a historian is documented.

I don't work in pediatrics, so I didn't keep the article as a reference, but if I find it again, I'll share link here.

Please do!

 

[sattenapallihruday]

Interesting. I code pro-fee for a physician group of pediatricians at a children's hospital. Our company policy is to give two points when a historian is documented.


Please do!

I agree with Thelton. We can consider 2 points only if the patient is not in the position to provide history, scenarios like- altered mental status/head injury with loc etc., for MDM-B: Reviewing History with other than patient. Otherwise we take 1 point only though the patient is younger and other than patient is giving history.

Thanks,

Hruday S, CPC

 

[Tami_F]

I agree with Thelton. We can consider 2 points only if the patient is not in the position to provide history, scenarios like- altered mental status/head injury with loc etc., for MDM-B: Reviewing History with other than patient. Otherwise we take 1 point only though the patient is younger and other than patient is giving history.

Thanks,

Hruday S, CPC

I am of course limited by my experience and that my current employer is the only place I have coded, however, 100% of that experience has been coding pediatrics. Not giving two points for an historian in pediatrics doesn't make sense to me. Is there an article or anything concrete you could share that might clarify this? I have looked through the entire AAPC E/M training in addition to poking around the internet, and found nothing that specifies treating an historian differently in pediatric cases.

I wonder, too, if it makes a difference in my department because another department policy is that we are required to use MDM in every visit we level.

I will ask this question in the Peds subforum linking to this thread and see if any peds experts can weigh in.

 

[danskangel313]

Copied from my ped post -

Maybe looking at it in other ways would be most helpful...

When determining the levels for HX, Exam, and MDM, you can't double-dip when leveling. Using the example in the other post, the mom states vomiting and fever for past 24 hrs. That would be the chief complaint and count into the HPI. If you counted the information from the mom into the MDM, then you'd have nothing left to use when calculating the HX/HPI. Without a CC, there's no basis for the medical necessity of the visit.

MDM comes into play after the history and exam are completed. The provider is deciding what to do based off the HX and exam. So with regards to obtaining information from another person for MDM, that would be historical information the provider decides is needed to better understand a current condition. In other words, it'd be the equivalent to obtaining old records for review.

There's a difference between "history" of present illness and medical "history". Is the provider obtaining the information to evaluate and treat the current condition (HX/HPI) or is the provider in need of additional information in order to determine what to do (MDM)?

 

[danskangel313]

To clarify and correct my previous post:

I found some additional information in an E/M practice book and went though all of the office visit examples. In every single one, if the parent is the only person who provides information, then you would not count it into the MDM. However, if the patient provides some information and the parent provides some information, THEN you can count the parent's information into the MDM.

There was no distinction as to the age of the patient, but using common sense, if a patient can provide relevant/accurate information, then they're old enough. This logic then also covers what to do when a patient cannot contribute to the office visit, such as if they're mentally incapable. The documentation would have to state the reason the patient couldn't provide information in such a case, but you could not apply the history from the caregiver to the MDM.

Does that help at all?