DecisionHealth, DecisionHealth - 2022 Issue 4 (April)

Unreliable ‘source’? Try others, and document the disagreement

Question: One of our providers had an office visit with a cognitively impaired patient and her adult daughter, whom he considers the “historian” in the encounter for E/M level selection purposes. However, the provider suspects the daughter’s version of events may be incorrect. What should he do? And can the daughter’s testimony still be used to calculate E/M levels?

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