General Surgery Coding Alert

Question: Would you please explain how taking the vital signs contributes to determining the E/M service's physical exam?

Georgia Subscriber

Answer: Checking any three vital signs will count as one bullet in the physical exam, based on the current (1997) documentation guidelines for E/M services, which you can find at (www.cms.gov/MLNEdWebGuide/25_EMDOC.asp). The 1995 guidelines do not specify the type or number of vital signs that count toward "taking vital signs."

Here's how it works: Under the current documentation guidelines for E/M services, 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 multisystem 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)/ 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 gastric bypass x 1 month. He complains of acid reflux x 5 days. He also complains of back pain x 2 weeks."

You could count this example toward multiple areas: (1) the history; (2) digestive system; 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).