Pediatric Coding Alert

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

New Hampshire Subscriber

Answer: Checking any three of seven vital signs will count as one bullet in the physical exam, based on the current (1997) documentation guidelines for E/M services, which you can find at (www.cms.gov/MLNEdWebGuide/25_EMDOC.asp).

Here's how it works: Under the 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

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