Wiki Documenting vitals

[lindab]

If vital signs are left off of the charting and enough docuementation is present without the vitals can the required ov level be billed?

 

[mhstrauss]

If vital signs are left off of the charting and enough docuementation is present without the vitals can the required ov level be billed?

Yes. I've never come across anything that says that vitals are required for an E/M service. As long as the exam that is documented is sufficient for the code billed, there shouldn't be any issues.

HTH!

 

[lmartien]

I would agree. You just could not count them as part of the history or physical exam components when assigning or auditing the E/M service.