June 24, 2021

Question:
I am a Dermatologist. I have a patient who was referred to my office who has dementia and was unable to provide her medical history. The patient’s granddaughter was able to provide the patient’s medical history to me as the patient was confused and unable to provide this information. Is there anything in the 2021 CPT guidelines for outpatient E/M services that clarify this point?

Answer:
Great question. This has been clarified in the 2021 E/M Guidelines for Office of Outpatient services that went into effect January 2021. Under the element of Data to be Reviewed and Analyzed, the new guidelines give MDM “credit” for taking a history from an independent historian(s). The guidelines define an independent historian as “An individual (eg, parent, guardian, surrogate, spouse, witness) who provides a history In addition to the history provided by the patient who was unable to provide a complete or reliable history (eg, due to developmental stage, dementia, or psychosis) or because it confirmatory history is judged to be necessary in the case where there may be a conflict or poor communication between multiple historians and more than one historian(s) is needed, the independent historian requirement is met.” This makes sense as the MDM is more difficult because the physician is taking the history from an observer rather that the individual experiencing the symptoms. The documentation should include who the historian is (relation to the patient as stated above) and why the patient is unable to give a complete history.

The 2021 CPT E/M guidelines have an entirely revised scoring system for MDM and it is important to understand it because the level of service depends on it.

*This response is based on the best information available as of 6/24/21.