# If only vitals are present, can that count towards consitutional component of exam?



## clarkmegan (May 15, 2018)

If only vitals are present, and no other elements are documented, can I count that as meeting the "consitutional" portion of the exam?  For example, this is for a new patient visit with no exam, however the vitals are present.  Would this qualify as 99201?


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## angbart80 (May 15, 2018)

clarkmegan said:


> If only vitals are present, and no other elements are documented, can I count that as meeting the "consitutional" portion of the exam?  For example, this is for a new patient visit with no exam, however the vitals are present.  Would this qualify as 99201?



I would count vitals as the "constitutional" part of an exam, but I would need to see the rest of the chart before I could code it as a certain level.  Why was the patient there?  Why was there no exam?  He really didn't listen to the patient's heart beat?  Or look into their throat, eyes, ears, or anything?  
I'm not sure on all the rules for addending charts, but maybe the doctor can add an addendum?


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## Pathos (May 15, 2018)

angbart80 said:


> I would count vitals as the "constitutional" part of an exam, but I would need to see the rest of the chart before I could code it as a certain level.  Why was the patient there?  Why was there no exam?  He really didn't listen to the patient's heart beat?  Or look into their throat, eyes, ears, or anything?
> I'm not sure on all the rules for addending charts, but maybe the doctor can add an addendum?



Getting the big picture is always paramount when auditing, however that said I would also be interested in knowing which CMS guidelines your (clarkmegan) clinic uses (1995/1997).
Our clinic uses the 1997 guidelines which allows for more specialties. This exam form requires at least 3 vital signs documented, 1) blood pressure (_sit/stand_), 2) blood pressure (_supine_), 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight.

If at least 3 of the above vital signs were documented, then I would count at least 1 exam element for the exam portion. You would still need a Problem Focused History with at least 1 HPI (or 1 chronic condition); a Straightforward Medical Decision Making. With New Patient/Consultation E/M visits, all three E/M components (History, Exam, MDM) must match in terms of complexity, otherwise the lowest component determines the E/M level (unless time is properly documented as an overriding factor).

If vitals are the only one thing documented and no History and MDM, then I would be very hard pressed to defend the visit against a future audit.

Hope this helps!


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## diannalambert (Aug 30, 2018)

*Vitals only*

If the vitals are the only portion documented, and most of us know that an MA, LVN, etc took those vitals and entered them, how can this be counted toward the Exam when a physician or mid level is supposed to perform the exam??  Would it be a valid E&M service if there is no exam and only vitals are there?  Regardless of the HPI, MDM, the exam is a key component that has to be performed by an eligible provider of the service?


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## Bernadette10 (Mar 13, 2019)

*Vital signs as part of exam*

Someone told me that when the provider signs the note, they are verifying the info in it and that they reviewed it, so the vital signs can be counted as part of the exam even if they were done only by a nurse. But I normally don't count them if it looks like they were only done by a nurse unless that's the only way to get a 99201 on a new patient, as long as there's also a history and MDM.


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