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 Subscriber

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 pressure

2. Supine blood pressure

3. Pulse rate and regularity

4. Respiration

5. Temperature

6. Height

7. 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 triple bypass x 1 month. He complains of shortness of breath upon exertion x 5 days with no chest pain. He also complains of back pain and leg cramps x 2 weeks."

You could count this example toward multiple areas: (1) the history; (2) respiratory system or cardiovascular system (not both); and (3) musculoskeletal system. There will be times you will need to make a decision whether a statement will count toward the history or a review of systems. In this example, you meet three bullets (either one history and two ROS; or three histories).