Internal Medicine Coding Alert

Published on Thu Jan 28, 2010 PDF

Question: Can you explain how many of the vital signs our new internal medicine physician needs to perform as part of an E/M service's physical exam?

Tennessee Subscriber

Answer: Under the 1997 documentation guidelines, the internist 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).

-- Answers to You Be the Coder and Reader Questions were reviewed by Bruce Rappoport, MD, CPC, CHCC, a board-certified internist and medical director of Broward Health's Best Choice Plus and Total Claims Administration in Fort Lauderdale, Fla.