# E/M visit without vital



## mracioppi (Sep 1, 2011)

Can anyone tell me if an E/M visit can be billed if the patient's vital were taken but not documented at the TOS?  The claim has already been billed to a commercial insurance co.


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## GaPeach77 (Sep 1, 2011)

It depends on which level you billed.

Simone


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## mracioppi (Sep 1, 2011)

simonewill7 said:


> It depends on which level you billed.
> 
> Simone



It was a level 4 E/M


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## kissie (Sep 1, 2011)

I am assuming you are talking about the physical exam portion. If you have enough bullets in the physical exam to cover a level 4 you should be fine, you don't have to have the constitutional points to get a four as long as there is enough others mentioned to cover.


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## mracioppi (Sep 1, 2011)

kissie said:


> I am assuming you are talking about the physical exam portion. If you have enough bullets in the physical exam to cover a level 4 you should be fine, you don't have to have the constitutional points to get a four as long as there is enough others mentioned to cover.



Thanks, but I was talking about if when the nurse takes the patient's vitals;  I was told that if 3 vitals weren't taken by the nurse, like blood pressure, ht/wt and temp, then you can't bill the visit.


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## FTessaBartels (Sep 12, 2011)

*1995 vs 1997 guidelines*

1997 guidelines require the documentation of 3 vital signs (can be performed by ancillary staff) to get ONE bullet under constitutional.

1995 guidelines have no such specification - even 1 vital sign will qualify as "constitutional." (As will a statement - "well nournished male.")

There is NO requirement that consituttional be one of the systems examined (though it's unusual when it isn't).  You simply count up the body areas/organ systems (1995) or the bullets (1997) and determine your level of exam based on what IS documented.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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