General Surgery Coding Alert

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 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.”

In other words, should your surgeon determine that the patient either cannot provide a complete, or even a reliable, history due to their age, and has turned to a patient’s parent or guardian to provide that history, either whole or in part, then you can count the testimony of a parent as fulfilling the category 2 requirement when calculating MDM at the limited level, which is used for office/outpatient E/M levels 99203/99213 (Office or other outpatient visit for the evaluation and management of a new/established patient, which requires a medically appropriate history and/or examination and low level of medical decision making …).