tci Outpatient Facility Coding Alert - 2016 Issue 11

Reader Question: Clear Up the Confusion Regarding Using an Interpreter in an E/M Visit

Question: This is a question about coding an E/M visit. If the patient doesn’t speak English and uses and interpreter during his office visit, is the physician able to count this in the medical decision making when, someone else other than the patient is providing the information? Texas Subscriber Answer: According to CMS guidelines, “A decision to obtain old records or decision to obtain additional history from the family, caretaker or other source to supplement that obtained from the patient should be documented.”(https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf) This means if the physician obtains additional history from...

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