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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