Internal Medicine Coding Alert

Published on Thu Nov 17, 2011 PDF

Question: Would you please explain how taking the vital signs contributes to determining the E/M service's physical exam?

Georgia Subscriber

Answer: 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.

Here's how it works: Under the current 1997 documentation guidelines for E/M services, performing (and documenting) any three of the following seven vital signs will count as one bullet in the constitutional system/body area of the general multisystem examination:

1. Sitting or standing blood pressure

2. Supine blood pressure

3. Pulse rate and regularity

4. Respiration

5. Temperature

6. Height

7. Weight.

The current 1995 documentation guidelines do not specify the type or number of vital signs that count toward "taking vital signs," but you need only one vital sign from the list above to count as one bullet and satisfy the vital signs credit for a 1995 physical examination.

Bonus: Ancillary staff (such as a nurse) may measure and record the vitals.