Focus on E/M services: Independent historian

Dec. 21, 2020 / By Colleen Ejak, RHIA

As we continue our Evaluation and Management (E/M) blog series on the revisions to E/M services for Office and Other Outpatient Services for New and Established patients, I want to take a deeper look at an important new term in the medical decision making (MDM) table: Independent historian. As I wrote in a prior blog, this assessment requiring an independent historian(s) is a component of the second element of MDM, the amount and /or complexity of data to be reviewed and analyzed.  In reviewing the American Medical Association’s (AMA) MDM table, an independent historian is a potential element of limited, moderate and extensive medical decision making. 

Independent Historian

So, who is an independent historian and how does that differ from the current MDM elements to E/M services?  Remember the revisions to E/M services for 2021 affect only the office and other outpatient services categories; for all other categories (where appropriate) the existing 1995 or 1997 guidelines remain in effect in 2021. Let’s compare the two:

Within the current E/M guidelines and according to the Centers for Medicare and Medicaid Services (CMS) table of risk, under the same element of amount and complexity of data reviewed, we see the following: “decision to obtain old records and/or obtain history from someone other than the patient”, and separately “review and summarization of old records and/or obtaining the history from someone other than the patient…” This element of MDM refers to information gathered beyond the history and physical, as this information increases the complexity of the MDM.  “Someone other than the patient” is not, in my opinion, clearly defined in the guidelines. In thinking of how this increases the complexity of decision making, I have educated physicians to document situations such as:

• A pediatric patient, who due to their age is not able to converse directly with the physician.
• An elderly patient with dementia or a prior stroke that has left them non-verbal.
• A mental health patient who is not a reliable historian.
• A patient who speaks a foreign language and an interpreter is needed.
• A trauma patient or acute injury patient who cannot give a full history.

This person(s) contributing additional history could be present during the encounter or the physician may need to call someone where the patient currently resides, such as the nursing home or assisted living home. Documenting this is, of course, required to support the complexity of care provided. 

The revised E/M guidelines for Office and Other Outpatient Services, effective January 1, 2021, continue to include an independent historian as a key element of complexity under the second element of medical decision making and provide a clear definition. The AMA defines an independent historian as “an individual (e.g. parent, guardian, surrogate, spouse, witness) who provides a history in addition to the history provided by the patient who is not able to provide a complete history or a reliable history (e.g. due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary.  

Let’s review an example of an office visit where an independent historian was judged to be necessary and the supporting documentation was well documented:

Office visit

Chief Complaint (CC): f/u for stable depression and mild recent forgetfulness.

History of present illness (HPI): 70-year-old male seen for follow up visit for depression. Visit attended by patient and daughter, history obtained from both. Patient and daughter report increasing distress related to finding that he has repeatedly lost small objects (e.g. key, bills, items of clothing) over the past 2 to 3 months. Patient states he notices intermittent, mild forgetfulness of people’s names and what he is about to say in a conversation; daughter confirms this detail.

An independent historian, as detailed in above example, does increase the complexity of medical decision making. This is a confirmatory example, but one the physician judged necessary. There will be other encounters that will present more conflicting details and more complexity; I’m sure you can recall a few based on your own experience.  

Watch for our next blog in the E/M 2021 changes series where we will discuss the use of time for E/M level selection and assess the revisions to the current guidelines.