ED Coding and Reimbursement Alert

Question: Can vital signs recorded by a nurse be counted as part of the physician exam if the emergency physician does not specifically reference them in his notes?

Louisiana Subscriber

 
Answer: ED physicians are compensated only for services they perform not for services provided by hospital staff. However, the physician can review the vitals and incorporate this information into the physical evaluation. In this instance, the information is considered to be part of the physician examination, albeit recorded by ancillary staff. It may then be factored with other aspects of the exam when determining which level of service may be coded and billed.
 
ED physicians and coders should note that vital signs alone may not be considered sufficient to support a physician examination of the constitutional system. Other information should be provided as well (e.g., notation of fever, physical appearance, etc.).