# Vitals documented by nurse in ED



## brookeborne (Sep 17, 2015)

Pro-Fee Coding:  When auditing/coding an ED record and the vitals are documented by the nurse, which their work is paid under the hospital, can you give credit for vitals in the exam as constitutional when determining the E/M level?


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## JJOHN0312 (Sep 18, 2015)

*Re: nurse documentation*

As far as I know, the physician needs to complete the physical exam portion of an evaluation and management service. This is a physician service and he/she is physically examining the patient. However, this can be counted in the ROS as long as he/she states that they have reviewed the vitals and states this in the documentation. CMS has the E&M guidelines on their website, as well as your local MAC. If this is BCBS, they have their own reimbursement guidelines.

Hope that helps!

_Josie, CPC, COC, CPMA_


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## sswisher (Sep 20, 2015)

Vital signs count toward exam and not toward ROS.  

1997 guidelines explicitly state that 3 of 7 VS are required but they may be measured and recorded by ancillary personnel.  (Probably safest for physician to put in a VSS noted statement or checkbox of some kind, although WPS specifically states VS entered at top of physician document may be assumed to have been reviewed--see link below.)  

1995 guidelines don't specify a number of VS that need to be recorded and don't discuss whether ancillary personnel may record them. However, the 1995 guidelines have generally minimal constitutional exam requirements and it's very easy to simply put "NAD" or "mild distress" or some other minimal notation and meet the constitutional exam requirements.  Also, VS can be extracted elsewhere.  For example, if CV exam lists RRR, that speaks directly to vital signs as RRR is typically a pulse rate of 60-100 (for adults).

https://www.cms.gov/Outreach-and-Ed.../downloads/eval_mgmt_serv_guide-ICN006764.pdf

http://www.wpsmedicare.com/j5macpartb/resources/provider_types/evalmngmntqa.shtml

http://www.codapedia.com/article_191_Do-you-need-three-vital-signs-for-it-to-count.cfm


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## JJOHN0312 (Sep 22, 2015)

*Re: Examination*

I would be very careful billing for an exam that was performed from other than the treating physician. See guidelines below from the evaluation and management guidelines. 9/22/15

E/M services refer to visits and consultations furnished by physicians and the following
qualified NPPs:
❖ Nurse practitioners;
❖ Clinical nurse specialists;
❖ Certified nurse midwives; and
❖ Physician assistants.
A NPP?s Medicare benefit must permit him or her to bill for E/M services, and the services must be furnished within the scope of practice in the State in which the NPP practices in order to receive payment from Medicare.


"Both the 1995 and 1997 DGs have information on the General Principles of Medical Record Documentation and one of the items shows what should be included in the documentation for each patient encounter."

"DG: The ROS and/or PFSH may be recorded by ancillary staff or on a form
completed by the patient. To document that the physician reviewed the
information, there must be a notation supplementing or confirming the
information recorded by others.
DG: If the physician is unable to obtain a history from the patient or other
source, the record should describe the patient?s condition or other
circumstance that precludes obtaining a history."

"The type (general multisystem or single organ system) and content of examination are selected by the examining physician and are based upon clinical judgment, the patient?s history, and the nature of the presenting problem(s)."


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## JJOHN0312 (Sep 22, 2015)

I think this is what you referenced? from wpsmedicare

Q18. When a medical assistant (MA) takes and records the vital signs in the chart of a flow sheet, does the physician need to include the information in his/her note or reference them in his note in order to receive credit under the "constitutional section" for E/M coding?
A18. Yes, the vital signs need to be referenced. If the MA wrote them in the flow chart, it would not be apparent the physician saw the vitals unless the physician actually referenced them or re-dictated them in his/her note.


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## sswisher (Sep 23, 2015)

Yes.  Also, you missed the second paragraph:  
"In a physician's handwritten note for a visit, the MA will usually write the vitals at the beginning. In that case, it would be a *fair assumption* that the physician saw and was aware of the vitals and agreed with the findings. In the case of a dictated note, it is *assumed* that the physician saw the vitals taken by the MA before he/she dictated them. In both of those scenarios, as long as it could be easily inferred from the physician's notes that the physician was aware of the vitals, nothing further would be necessary."


Also, the 1997 guidelines note for constitutional exam:
"Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (*May be measured and recorded by ancillary staff*)"


So back to the original question:  Can you give credit to the clinician for VS that were not actually taken by him or her?  Yes, under 1997 guidelines or for WPS.  The clinician should note the VS in some way, but need not perform the VS measurements him/herself.

For those using 1995 guidelines, the physician should write "Mild distress" (or whatever is accurate) and not worry about recording VS unless necessary for patient care.


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## JJOHN0312 (Sep 24, 2015)

We are in a world of EHR. It would be very rare for a physician to document written notes. Those would take special consideration. In my professional opinion, if I were auditing, the physician would need to reference the vital signs and that he/she reviewed, or else I would not be able to count that in the exam portion of the audit. 

Thanks!

Josie Johnson, CPC, COC, CPMA


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## brookeborne (Sep 25, 2015)

Josie

I agree with you.  If the provider referenced the vitals in some way I would give them credit for the Vitals

Thanks everyone for the feedback and documentation received.

Greatly Appreciated!


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