Pulmonology Coding Alert

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

Georgia Subscriber

Answer: Checking any three vital signs will count as one bullet in the constitutional system of 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 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:

• Sitting or standing blood pressure
• Supine blood pressure
• Pulse rate and regularity
• Respiration
• Temperature
• Height
• Weight.

The 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 element and receive credit for the constitutional system of the 1995 physical examination.

Remember that any of your ancillary staff (for example, a nurse) may measure and record the vitals.