I have a NP who works pediatrics and does a wonderful job of documenting if her HPI/ROS is obtained from the patient (15 year old, etc.) or if it is obtained by someone else (Mother states…).
We have a debate in our office on if this should be counted in determining the E/M level in the "Data" are as obtaining history from someone other than the patient. They feel that this should only apply to pts whos medical condition prevents the patient from giving information and it does not pertain to patients who are prevented because of their age.
I disagree. I feel that regardless of WHY the provider can’t get the information directly from the patient, it is still second hand information that adds a level of difficulty to their MDM.
We have a debate in our office on if this should be counted in determining the E/M level in the "Data" are as obtaining history from someone other than the patient. They feel that this should only apply to pts whos medical condition prevents the patient from giving information and it does not pertain to patients who are prevented because of their age.
I disagree. I feel that regardless of WHY the provider can’t get the information directly from the patient, it is still second hand information that adds a level of difficulty to their MDM.
Does anyone have documentation and/or sources I can refer to in sorting this out?