Wiki obtaining history from parents/guardians

[apollo06]

I am looking for some sort of guideline, where it states or infers that providers may not receive credit in a audit (2 pts in the MDM section) for obtaining history from the parents/guardians just because the patient is a infant/toddler. Ive heard you may only get credit if the patient has a medical reason has to why they cannot give a history and of course supported by documentation. I have providers who want to see this guideline because I am not giving them credit. Any help would be great. Thank you

 

[Pam Warren]

I don't know of any specific guideline, but the data points were crafted to give additional credit when provider/patient communication was hampered such that docs had to sort through additional external information to draw their conclusions. For example, when an elderly spouse contradicts the history such that two scenarios have to be sorted out, or if a patient needs an interpreter who repeats information in another language, without the provider really knowing if the translation is valid. In the case of obtaining information from parents/guardians of infants, well, that's the standard method for obtaining history, so information is being received in the normal way. One would hope that the information that mom is giving is complete and correct, but that's the only way the provider's going to get that information. Think about it. In the real world, the infant wouldn't ever step up and announce 'wait!!....my mother's confused!!....I had two bowel movements yesterday!' You get my point. The parent is always going to be the primary method of communication regarding infants, so getting two additional points for that is inappropriate.

 

[suemt]

I would be inclined to disagree. It is precisely because the infant cannot speak for themselves that the provider's MDM is more complex. The provider must rely on the translated/interpreted explanations and descriptions from the (potentially biased) parent.

To use the examples previously mentioned, the provider needs to hear the 'translation' from the parent and determine if it is valid (is the parent over worried? projecting? hiding something?)

Also, just because the infant isn't speaking the same language as the provider, they are certainly able to communicate things such as pain in certain areas, overall demeanor, etc. And if these contradict what the parent is reporting, the provider has potentially more complex MDM.

I'm interested to hear what others have to say about this.

 

[KERRIEA]

I agree with Sue and interestingly enough I just attended a coding seminar with a nurse/coder/consultant who stated that she believes you should get credit for obtaining the history from the parent when the child is unable to provider it themselves for any reason.