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As of 1/1/2023, CMS has eliminated prior specifications for documentation of a patient’s history for services provided in both the outpatient office and hospital setting, including the emergency department. The 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.
History
- 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 in the outpatient/office and hospital setting, including the emergency department. 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.
- 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: CMS has clarified that practitioners may not re-enter information in the medical record on the patient’s chief complaint and history, when it 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
- When a patient is not able to provide a complete and reliable history, which individuals may fulfill the role of “independent historian” when calculating MDM credit for this factor when coding as an E/M service?
Answer:National Government Services recognizes the AMA description of an independent historian,: “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.” This guidance applies to history obtained in all sites of service for all E/M service categories.
- 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.”
Reviewed 4/15/2024