The Problem with Independent Historians

April 8, 2024

In most cases, we know who independent historians are: mothers, fathers, guardians, grandparents, or adult children. But we still see many instances when the term is incorrectly applied in the documentation—mostly, it seems, because of misunderstandings about when someone providing information qualifies as an independent historian.

In clearing up the confusion, let’s go back to the definition: The American Medical Association (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 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.”¹ In essence, the independent historian assists in gathering relevant historical information when the patient’s own account is insufficient or unreliable. Their role is crucial in ensuring accurate medical assessments and decision-making.

The problems often arise over the phrases “in addition to the history provided by the patient” and “relevant historical information.” For example, we see documentation of many encounters where a spouse or parent is counted as an independent history for providing additional information even though the patient could verify information on their own.

Here’s a specific illustration. A patient’s wife accompanies her husband to the encounter and contributes additional information, such as noting that he isn’t sleeping well at night or that she has advised him to drink cranberry juice because he isn’t urinating well. In such a case, the spouse is not serving as an independent history because her husband can provide that information for himself. The spouse’s added details may be relevant but should be considered as contributing information, not an independent history.²

We also see a number of questions about validating an independent historian for pediatric or geriatric patients. Are there age limits? Shouldn’t we validate for everyone?

¹2023 CPT E/M descriptors and guidelines (ama-assn.org), p. 17

²National Alliance of Medical Auditing Specialists, Independent Historian – NAMAS

Remember, you’ll need three components for complete documentation of an independent historian:

(1) First, document that a historian was involved;
(2) Document the reason why an independent historian was needed (that is, why the patient could not provide “a complete or reliable history” for themselves; and
(3) If other sources provided pertinent information (such as a home aid, group home attendant, teacher, police officer, or social worker), specifically document each of these.

Given all of these possible sources of information, it makes sense to create a template that you can use for these scenarios, such as:

The patient was seen at _______ years/months old, in conjunction with ____________(role of the person who accompanied the patient to the encounter), and based on the developmental age of the patient, the _____________ (person serving as the historian) reports that _______________________. The patient was unable to furnish a complete or reliable history because ______________________________________________ (information on the patient’s limiting conditions, such as dementia, psychosis, or stroke with aphasia).³

The provider can easily complete the information in this template and fulfill the requirements for an independent historian. Alternatively, the provider can simply incorporate this information into the documentation as the exam continues. Use whichever approach is easier for accurately documenting the information.

Remember: To receive proper credit for the independent historian, include the proper documentation, the reason why the historian was needed, and the person(s) supplying the “history.” While it can be helpful for a wife or child to bring up issues on behalf of their spouse or parent, this information cannot be credited towards the MDM (medical decision-making) if the patient can speak for himself as a competent historian.

³Independent Historian – NAMAS

Got a question about E/M coding? We’d love to hear from you.

Submit your questions by emailing us at coders@calmwatersai.com

Download PDF

Michelle Sergei-Casiano CPC, CFPC, CEMC, CPMA Senior Manager, Regulatory and Coding Compliance coders@calmwatersai.com