Wiki When Vital signs are missing from an OV

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cwestman

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The OV was a routine f/u for a patient with multiple commorbidites ,the level easily qualified for a 99214,however no Vitals were documented.
I queried the office manager who investigated and responded that it appeared to be an Eclincal (EMR)error apparently both the provider and the nurse were in the chart so when the vitals were entered apparently they were not retained .
I'm wondering what if anything can be billed for this OV
The same Incident occurred with an IPPE exam as well which would be a G0438,however no vitals were retained
Appreciate your time and help
Thanks Cheri
 
Vital signs are not a requirement in order to bill an office visit - they are only one possible component of the exam portion. You can code the visit based on the information that is actually documented in the record.

For the IPPE and AWV though, as I understand it, all elements must be performed. Since height, weight, BMI and blood pressure are required, those visits might not be billable.
 
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