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History Element for data

  1. #1
    Default History Element for data
    Medical Coding Books
    For the pediatric population, if history is also given by a parent because of childs age, should an auditor allow credit under data for obtaining history from someone other than the patient? Should this credit be allowed for non speaking children only or for all ages?

  2. #2
    Milwaukee WI
    Default Grey area
    This is a grey area.

    Some auditors give credit in data points for this all the time. Some only give credit part of the time. Some never give credit.

    We consider the parent IS the patient if the child is so young that s/he is not able to give a history on his/her own. If the child is older and would be able to give his/her own history, then we would consider additional information obtained from the parent in looking at the data points.

    Hope that doesn't further confuse things for you.

    F Tessa Bartels, CPC, CEMC

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