Oncology & Hematology Coding Alert

Question: Our provider recently performed an evaluation and management (E/M) service on an elderly woman who did not speak English but who bought along her daughter who acted as a translator. Under the new E/M guidelines, would the daughter be considered an independent historian?

AAPC Forum Participant

Answer: Under the current office/outpatient E/M guidelines, an independent historian is “an individual (eg, parent, guardian, surrogate, spouse, witness) 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, dementia, or psychosis) or because a confirmatory history is judged to be necessary” per the CPT^® definition.

Based on this definition, the daughter in your scenario would not qualify as an independent historian if all she did was translate for her mother. However, if the daughter added to the mother’s history per the definition, which would seem reasonable given the patient’s age, then you could make a case for the daughter to be regarded as an independent historian. If that is the case, then you can count the daughter’s contribution to the E/M service as a data point in the amount and/or complexity of data reviewed and analyzed element of medical decision making (MDM).