Cardiology Coding Alert

Question: Can you explain how many of the vital signs our physician needs to perform as part of an E/M service's physical exam?Tennessee SubscriberAnswer:Under the 1997 documentation guidelines (www.cms.gov/MLNEdWebGuide/25_EMDOC.asp), 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 multi-system examination:1. Sitting or standing blood pressure2. Supine blood pressure3. Pulse rate and regularity4. Respiration5. Temperature6. Height7. Weight.Ancillary staff (for example, a nurse) may measure and record the vitals.Note: The general multi-system examination also covers general appearance of the patient (for instance, development, nutrition, body habitus, deformities, and attention to grooming).Bonus tip: When calculating bullet points, counting the same finding(s)/result within multiple component sections of your E/M service is not appropriate. So if you count an element in the history, you cannot count it in the review of systems.Example: Suppose documentation states, "Patient is status post [...]