In looking at the “Data” section of the medical decision-making portion of code selection, one of the points is “decision to obtain history from someone other than patient” and another is “obtain history from someone other than patient.” How does this apply in pediatrics, as more than 95% of the time we get history from the parent or guardian?

The documentation guidelines acknowledge that there are natural patient group variations on history and examination and though not specifically defined in the guidelines, these variations are appropriate. It is important to look at the medical decision-making elements in the context of physician effort. A decision to obtain old records or additional history from others should be an increase in the amount and complexity of data to be reviewed rather than the typical effort of acquiring a young child’s history.

Such an increase in amount and complexity of data may occur when...

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