Wiki E/M Data Box for MDM question - pediatrics

[wrightju1]

Ok, I got 47 views, but I'm hearing crickets on replies to a question I posted. So, let me try again.

Does anyone give credit in the "data box" for "history obtained from other than patient" in determining MDM level for office visits for pediatric patients that are too young to give good history, and the provider documents well that it was obtained from mother?

I've heard from one certified pediatric coder that she does give credit. Can I get more feedback from the group to help sort this one out?

 

[cldavenport]

This would be interesting information to know. I have audited pediatric visits but my providers do not add that statement that "info obtained from the mother". We just assume it comes from the parent because the child can't speak up.

Chanel

 

[Pathos]

This would be interesting information to know. I have audited pediatric visits but my providers do not add that statement that "info obtained from the mother". We just assume it comes from the parent because the child can't speak up.

Chanel

I agree with Chanel. When patients are unable to provide information (pediatric, mental state, etc) I don't believe it would be appropriate to count that Data box as well. The intent of that Data box, is to supplement information with what has already been given. In this case, this information is the only source and should not be counted extra towards that Data box.

Hope this helps!