tci ED Coding & Reimbursement Alert - 2006 Issue 1

Reader Questions: Ask Payers for Vital Signs Number

Question: Our practice is debating how many vital signs we need documented to count as a -constitutional- exam. The 1997 documentation guidelines indicate that we need three out of seven. Does this apply to the 1995 guidelines as well?For example, the physician indicates blood pressure only in his physical examination, and he did not document whether he reviewed the nursing notes (which contained documentation of three vital signs). In this case, I said that we couldn't count the vital signs. Was I correct?Massachusetts Subscriber Answer: For Medicare carriers using the 1995 guidelines, you are correct. But because...

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