SEP 19, 2022
Is an Interpreter an ‘Independent Historian’
Does using an interpreter or google translate allow you to choose higher-level evaluation and management (E/M) code for your office visit?
Answer:
From the AMA's E/M Code guidelines: “Independent historian(s)” are individuals (e.g., parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (e.g., due to the patient’s developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary. In the case where there may be conflict or poor communication between multiple historians and more than one historian is needed, the independent historian requirement is met. It does not include translation services. The independent history does not need to be obtained in person but does need to be obtained directly from the historian providing the independent information.