April 2023 page 23
Questions and Answers
Evaluation and Management: Evaluation and Management (E/M) Services Guidelines
Question: If a pediatric patient is unable to provide their medical history because of their developmental stage and/or age, does the
parent or guardian who then provides the history count as an independent historian? The definition of an independent historian
states that the individual must provide a history in addition to a history provided by the patient. Therefore, does a parent providing history for a newborn fulfill the “in addition to”
requirement to count or qualify as an independent historian?
Answer: Yes, the...
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