Primary Care Coding Alert

Question: A daughter brought her mom to our office. The mother was seen by the doctor, but he didn’t take any vitals (it was after normal office hours and the nurse was gone for the day). He documented the office visit for this “no appointment add on” service, but thinks we can’t bill for the encounter since we didn’t take vitals. He did document everything else (history, exam, medical decision making). I think we can bill for the visit, but can’t find documentation supporting my opinion. Who’s right? 

Texas Subscriber 

Answer: In this case, you’re correct. Vitals are not required in order to bill an E/M visit. Vitals are important – and usually the norm – but really are just another component of the exam. Since the physician documented the history, exam, and level of medical decision making, he should have sufficient notes for you to choose the correct E/M code.