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

Article Overview

This article explains a CPT evaluation and management documentation issue for encounters involving a cognitively impaired patient and another person providing history. It focuses on when outside historical information may support E/M data review and complexity, what to do when the provided account seems unreliable, and why documentation and practice compliance processes matter. The piece is aimed at coders, billers, and clinicians working with office or outpatient E/M services and prolonged services guidance.