Neurology & Pain Management Coding Alert

Question: I am working as a coder for the first time and one of my providers wrote that they received information about the patient from an “independent historian.” I don’t think the patient is an important political figure or anything, and they’re also still alive, according to their record, so I don’t understand what a historian has to do with their encounter. Is this a medical term?

Indiana Subscriber

Answer: Yes, an independent historian is a person who provides information or additional context about a patient’s history when the patient cannot. A provider may also seek information from an independent historian if they feel like they need confirmatory history.

The AMA says an independent historian may be a parent, guardian, surrogate, spouse, or witness who provides history beyond what a patient provides due to the patient’s developmental stage or conditions, such as dementia, or psychosis. The independent historian does not need to meet with the provider in person, but the provider must get the information directly from the independent historian.

The provider should document the reason that an independent historian was required, i.e., the patient is suffering from dementia, so their caretaker acted as an independent historian.

Remember: An interpreter or translator does not count as an independent historian, says Terry Fletcher, BS, CPC, CCC, CEMC, SCP-CA, ACS-CA, CCS-P, CCS, CMSCS, CMCS, CMC, QMGC, QMCRC, owner of Terry Fletcher Consulting Inc. and consultant, auditor, educator, author, and podcaster at Code Cast, in Laguna Niguel, California, because the patient is providing their own history.

However, using a third-party interpreter can affect time, if the interpretation makes the encounter last longer than it would have if conducted in a language the provider understands.