Wiki Vitals stating reviewed by provider? HELP!

[DK47]

Hello,

In order to count on the E/M coding I read that the vitals must state they were reviewed by the provider in order to count towards the level of service.
Can someone point me towards the documentation? 1997 Guidelines

Also if they are reviewed do they need to be done on same day of service as the visit in order to count? Thank you any help would be great

 

[teresabug]

Hi,
Vitals are not a requirement of an e/m code. The elements that a provider must review are those that can be documented by other staff: the chief complaint and the ROS. I have never seen in writing where the provider must document that he reviewed the vitals.
Anyone else that believe this to be otherwise, please post the confirming source.

Teresa

 

[DK47]

Thank you! I don't think I explained everything I needed to.
I am coding a Psychiatric 1997 E/M and the note has everything it needs for a 99215 except the vitals and "All Constitutional and Psychiatric and 1 bullet in Musculoskeletal box must be checked.

I can't remember if the note needs to say "reviewed (or something to that effect) by the "provider". The note just states "see nurse note" for vitals.

 

[thomas7331]

Yes, if your speaking of vital signs as a bullet point for the exam, the 1997 guidelines do incate that they 'May be measured and recorded by ancillary staff' - it's in the detailed description of the bullet points in the exam tables. They need at 3 of the 7 measurements to count that bullet point on the exam.

Thomas Field, CPC, CEMC