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Obtaining history in ED

  1. #1
    Default Obtaining history in ED
    Medical Coding Books
    In relation to the medical decision making, is it appropriate to give credit for making a decision to obtain history from sources other than the patient, which according the the guidelines increases the complexity of the data to be reviewed, when the patient is an infant? The physician is arguing that it is ok to increase the medical decision making if the patient is unable to give their own history regardless of the age of the patient.

  2. #2
    Milwaukee WI
    Default One data point
    Well the decision to obtain history from someone other than patient is only worth one point. Is the doctor saying that s/he conciously decided to get the history from someone else; if s/he hadn't decided this, s/he would have gotten this history directly from the patient, then?

    I would be more comfortable looking at problem points and risk to determine the total MDM than having to rely on this one data element to put me into a higher category.

    That being said, I do recognize that one of the difficulties in pediatrics, especially when dealing with an infant, is that the patient can't really tell you what is wrong. You definitely can get two data points for obtaining a history from someone other than the patient. BUT, in pediatrics the "patient" frequently means the parent.

    I'm sorry I can't be more definitive. All the rules/guidelines are made on the assumption that you have an adult patient (especially since Medicare seems to drive the healthcare bus, we all go where the driver takes us).

    I hope that helps.

    F Tessa Bartels, CPC, CEMC

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