EM Coding Alert

Question: Our urgent care center saw an infant for an upper respiratory infection. Under the 2021 office/outpatient E/M guidelines, can a parent be regarded as an independent historian for an infant patient and, if so, does that fulfill the requirements for category 2 in the data element when calculating the level of medical decision making (MDM)?

Illinois Subscriber

Answer: In the CPT^® 2021 guidelines, a parent is given as one of the examples of an independent historian. The guidelines go on to define an independent historian as “an individual … who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (eg, due to developmental stage …) or because a confirmatory history is judged to be necessary.”