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 SubscriberAnswer: 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 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, [...]