tci General Surgery Coding Alert - 2021 Issue Q1

Reader Questions: Know When to Use ‘Independent Historian’

Question: Our surgeon evaluated an infant in the office for correction of a birth defect. In choosing the evaluation and management (E/M) code, I’m wondering if we can count the parent as the independent historian, and does that fulfill the requirement for category 2 in the data element when calculating the level of medical decision making (MDM)? Illinois Subscriber Answer: Yes, you can count the parent as an independent historian, based on an example given in the CPT® 2021 guidelines. The guidelines go on to define an independent historian as “an individual … who provides a history...

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