Counting pediatric parent reporting as MDM data

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Joined: Tue Dec 29, 2015 10:20 am

Wed Oct 25, 2017 12:36 pm

I have a provider that insists her use of information from the parent of a 3 year old should be counted as data points in MDM (decision to obtain history from someone other than patient). I cannot find a resource that even addresses this. I wouldn't think that a 3 year old would be a reliable source and therefore would expect the parent to be the reporter and as a rule I wouldn't count this as additional data points. Can anyone refer me to any kind of guidance that would help with this? It would be greatly appreciated. Thank you.
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Wed Nov 22, 2017 10:14 am

If a caregiver has to provide the history because the patient is unable to provide it, it is seen as the same as the patient providing it. Whether its their parent, nurse, guardian, etc., it only counts as additional medical decision making when the conversation provides additional information/insight that could impact treatment.

An example where it is not supported would be, the mom bringing in her 3 year old. The 3 year old cannot provide their own medical history. or a nurse bringing in a nonverbal/nonresponsive patient from a care facility for a sudden fever. The patient is incapable of providing their own history, the nurse provides the HPI to explain why the patient needs to be seen.

In these examples, the patients caregiver is the one concerned, and providing the history. Now if the patient is able to provide some, or all of their own history, then with proper documentation, the discussion to obtain the history from someone other than the patient can be used. There should be other responses in this forum as well, regarding this topic.

I hope this helps. Your question has been answered by Omega Renne, CPC, CPCO, CPMA, CEMC, CIMC
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Joined: Sat Dec 16, 2017 10:58 am

Sat Dec 16, 2017 11:20 am

Can you provide any resources that state this outright that I can share with providers? It is an ongoing issue.
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