Primary Care Coding Alert

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 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:

The current 1995 documentation guidelines do not specify the type or number of vital signs that count toward "taking vital signs," so you need document only one vital sign from the list above to count as documenting a physical examination of the "Constitutional" organ system under the 1995 guidelines.

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