June 25, 2020
I am a pediatric orthopaedic surgeon and many of my patients are too young to give a history. My coders have never given me medical decision making (MDM) credit because they say it is part of dealing with children. Is there anything in the 2021 CPT guidelines for outpatient E/M services that clarify this point?
Great question and you are going to like the answer! This has been a common misconception amongst coders when young children are patients and they are unable to give a history due to their inability to talk. This has been clarified in the revised E/M guidelines that go into effect in January of 2021. Under the element of Data to be Reviewed and Analyzed, the new guidelines give MDM “credit” for taking a history from an independent historian(s). The guidelines define an independent historian as “An individual (eg, parent, guardian, surrogate, spouse, witness) who provides a history In addition to the history provided by the patient who was unable to provide a complete or reliable history (eg, due to developmental stage, dementia, or psychosis) or because it confirmatory history is judged to be necessary in the case where there may be a conflict or poor communication between multiple historians and more than one historian(s) is needed, the independent historian requirement is met.” This makes sense as the MDM is more difficult because the surgeon is taking the history from an observer rather that the individual experiencing the symptoms. The documentation should include who the historian is (relation to the patient as stated above) and why the patient is unable to give a complete history.
The 2021 CPT E/M guidelines have s an entirely revised scoring system for MDM and it is important to understand it because the level of service depends on it.
*This response is based on the best information available as of 06/25/20.