Wiki Peds MDM - how many points for historian?


Best answers
Hi Peds! There was a question posted in the Medical Coding General Discussion subforum recently that I hope someone here can help answer. Here's the thread.

Basically, we are discussing how many points to give for a parent acting as an historian for a pediatric patient. How do you count it? Any references you may have to back up giving points for historians would be much appreciated. I have struck out in my own searches.
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)?

I'll repost this to the other thread.
Reposting from original thread

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?