Outpatient Facility Coding Alert

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 a source other than the patient, then you can count this in the medical decision making (MDM). But in this scenario, a language translator is doing his/her job of translating just what the patient is saying. You cannot consider this an additional source, so you cannot count this for data reviewed in MDM.

If you think that use of a language translator causes your physician to spend a lot of time with the patient, then you may need to consider time-based coding. 

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