David Posted Mon 19th of September, 2016 16:51:00 PM
I have a question about coding an E/M visit. If the patient doesn't speak English and uses and interpreter during his office visit, is the physician able to count this in the medical decision making under the date to be reviewed, as they are obtaining history from someone other than the patient which gives them 2 point in that category?
I have never used that in the past, but recently learned of it being used by other providers.
I appreciate your feedback.
SuperCoder Answered Tue 20th of September, 2016 03:27:51 AM
Greetings from SuperCoder!
As per CMS guidelines, “A decision to obtain old records or decision to obtain additional history from the family, caretaker or other source to supplement that obtained from the patient should be documented.”
This means if physician obtains additional history from source other than the patient, then you can count this in MDM. But in this scenario, a language translator is doing his/her job of translating just what the patient is saying. We cannot consider this an additional source. So we cannot count this for data to be reviewed in MDM.
If you think that because of language translator your physician is spending a lot of time, then you may do time-based coding.