tci General Surgery Coding Alert - 2011 Issue 9

Reader Question: 3 'Vitals' Make 1 Bullet

Question: Would you please explain how taking the vital signs contributes to determining the E/M service's physical exam?Georgia SubscriberAnswer: Checking any three vital signs will count as one bullet in the physical exam, based on the current (1997) documentation guidelines for E/M services, which you can find at (www.cms.gov/MLNEdWebGuide/25_EMDOC.asp). The 1995 guidelines do not specify the type or number of vital signs that count toward "taking vital signs."Here's how it works: Under the current documentation guidelines for E/M services, performing (and documenting) any three of the following seven vital signs will count as one...

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