Tough topics and gray guidelines are what we like to cover in these “Takes,” and this one is no exception. Independent Historian did get cleared up somewhat with 2021 guidelines, but there are still some nuances there.
2021 guidelines did bring about a definition for Independent Historian. It cleared up some of that grayness that identified a parent, guardian, surrogate, spouse… and it gave us clarity and specifically identified who could be an Independent Historian. However, it also added with the definition what cases an Independent Historian could be used and why. Because it added those definitions with it, does that create the need for our provider to now identify why an Independent Historian is required? Have you thought about that?
The definition specifically states that an Independent Historian is used to provide history in addition to history provided by a patient who was unable to provide a complete or reliable history or because a confirmatory history is judged to be necessary.
So, a lot of times prior to 2021, we would see a note in which perhaps a husband was being seen, and the wife would add contributing elements; maybe that the husband wasn’t sleeping well at night, or the wife told the husband that he should drink cranberry juice because of not urinating well, and we would add that as an Independent Historian. That is contributing, that is not history in addition to for someone who is unable to provide reliable history. This really isn’t an Independent Historian. Before we credit Independent Historian under 2021 guidelines, we should go back and really assess what the rules are for Independent Historian.
Now, what does this do in the world of, say, Pediatrics or Geriatrics? Should we also be requiring the provider to validate the need for an Independent Historian? I mean, we do require providers to have medical necessity for most everything they do, correct? When a provider is performing a procedure, we require that the provider have medical necessity or clinical indications for that procedure. If a provider is ordering the service, there are clinical indications. So, if they are going to have an Independent Historian, shouldn’t they validate the need for the historian? Shouldn’t they identify that the patient has dementia? If we want them to document that a patient who is 65 or 70 has dementia-related needs or a patient who is 40 that has psychosis and requires a Historian, then why do we require it for some and not for all?
As my good friend Scott mentioned to me one time before, as an auditor, why do I have to be the bearer of at what age that patient is in a pediatric setting and is not able to be their own historian? This is a great time for the provider to create a macro that says the patient was seen at _______ years/months old, in conjunction with ________, and based on the developmental age of the patient, the _____________ reports ______________. That can easily be completed on behalf of the patient, and the macro now fulfills and identifies the reason for the Independent Historian from a medical necessity standpoint and also substantiates the need. So, we have identified the Independent Historian and also the medical necessity for the Independent Historian.
You need to create an internal policy as to what your expectations are. Whether in a pediatric setting, in a geriatric setting, in the ED setting, or the inpatient setting, what do you expect? Who is the Historian? What information the historian provided, and realistically, why was a historian required during that independent encounter for the provider?
Just some food for thought. Look at the rule, break it down for yourself, and have a meeting with your compliance team to determine what would be best practices for your organization. You can find this on the 2023 expansions of the 2021 guidelines on page 17.
I hope this has been helpful knowledge for you today. If you have any questions or comments about this, don’t hesitate to contact me at any point in time at namas@namas.co. You can also take a look at my video on this topic on the NAMAS YouTube channel (be sure to subscribe!).
Your next steps:
- Schedule a consultation for 2023 audit planning and a provider documentation review.
- Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
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