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As of 1/1/2021, CMS has eliminated prior specifications for documentation of a patient’s history for services provided in the outpatient and/or office setting (CPT code range 99202-99215). In the outpatient and office settings, a provider is expected to obtain and document medically necessary and relevant history details pertaining to the service and/or to review separately obtained history as applicable.

In the emergency room and all inpatient settings history requirements remain unchanged and are subject to CMS E/M 1995 or 1997 guidelines. Refer to History Prior to 12/31/2020 for related guidelines.

History On or After 1/1/2021

  1. What are the required elements of history for a detailed or comprehensive level of service?

    Answer:
    There are no specific CMS requirements for the scope or detail of history during an outpatient or office E/M service at any level. The scope of history is determined by the examiner, based on medical necessity relative to the presenting complaint and to other known comorbidities that may require the examiner’s attention. Reviewed 1/19/2021
  1. In the office/outpatient setting, what are the CMS documentation guidelines for who may elicit and document the patient’s history and how the provider may refer to previously recorded information in the medical record?

    Answer:
     As per CMS MLN Matters® MM11063: Summary of Policies in the Calendar Year (CY) 2019 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List, effective 1/1/2019, CMS modified previous rules relative to history discussion and documentation.

    “For established patient office/outpatient visits, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed. Practitioners should still review prior data, update as necessary and indicate in the medical record that they have done so.

    CMS is clarifying that for E/M office/outpatient visits, for new and established patients for visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.” Revised 1/19/2021
  1. When a patient is not able to provide a history, due to altered mental status or physical impairment, can credit be allowed when history is elicited from a family member or authorized patient representative?

    Answer:
    When the patient is unable to provide a history of the present illness it is permissible for the provider to obtain and document history obtained from the patient’s family member or authorized representative. The source of this history should be noted in the medical record for the service. Reviewed 1/19/2021

  2. Which individuals may fulfill the role of “independent historian” when calculating MDM credit for this factor when coding an E/M service?

    Answer: NGS recognizes the AMA description of an independent historian, which is as follows:

    “Independent historian(s): An individual (e.g., 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 (e.g., due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary. In the case where there may be conflict or poor communication between multiple historians and more than one historian(s) is needed, the independent historian(s) requirement is met.” Revised 1/22/2021

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History On or After 1/1/2021
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