Independent Historian: Are We Really Dying on This Hill?

I have to admit, I am always a little surprised by how much conversation the independent historian generates when we talk about E/M auditing. We debate whether the patient could provide a complete history, whether the parent or spouse added enough information, whether the provider sufficiently explained why the additional history was necessary, and whether we can give credit for the element. These are legitimate questions when the independent historian matters to code selection, but sometimes I think we are giving this one piece of MDM far more attention than it deserves.

Let’s put it back into perspective. An independent historian is one element within the amount and complexity of data to be reviewed and analyzed. Data is only one of the three elements of MDM, and two of those three elements are required to support the overall level. In other words, we can spend a tremendous amount of time debating whether one piece of the middle column counts when the problems addressed and the risk of patient management may already be doing the heavy lifting in determining the level of service.

That does not mean we ignore the requirements. If an independent historian is being used to support the data category and that data is necessary to reach the reported MDM level, then absolutely, audit it. The CPT definition matters. The independent historian is an individual who provides history in addition to the history provided by the patient when the patient is unable to provide a complete or reliable history, or when a confirmatory history is judged necessary. The guidelines also tell us that the independent history does not need to be obtained in person. Those are the criteria we should apply when the element matters.

But here is where I think experienced auditors need to exercise some perspective. Before spending significant time debating whether the independent historian qualifies, remove it from the equation. What happens to the code?

If the level of MDM does not change, we may be having a fascinating auditing discussion that has absolutely no impact on the audit result.

I see this happen more often than you might think. We find one questionable element and immediately start dissecting it because we want to determine whether we can give credit. Meanwhile, we have not stopped to ask whether we even need that element. That is not necessarily better auditing. Sometimes it is simply more auditing.

This is also where understanding the structure of MDM becomes so important. The goal is not to collect every available element in the table. We are determining the level of medical decision making supported by the encounter. Problems addressed and risk frequently tell us a great deal about the complexity of that encounter. Data certainly matters, and in some encounters it will be essential to determining the level. But it should remain in its proper place within the overall MDM analysis.



So yes, know the definition of an independent historian. Know when it qualifies and how it contributes to data. But perhaps we can stop treating every independent historian discussion like it is the defining issue of the E/M audit.

Before going down that rabbit hole, ask one simple question: Does it change the code?

If the answer is no, document your observation if appropriate and keep auditing. Knowing what deserves our attention is part of being an experienced auditor too.