Part B Insider (Multispecialty) Coding Alert

Published on Tue Aug 02, 2011 PDF

Question: I read your previous article on "double dipping" with great interest (the Insider, Vol. 12, no. 30) and I have a follow-up question. Can you please explain how taking the vital signs contribute to determining the E/M service's physical exam?

Answer: Checking any three vital signs will count as one bullet in the physical exam, based on the 1997 documentation guidelines for E/M services, which you can find at www.cms.gov/MLNEdWebGuide/25_EMDOC.asp.

Here's how it works: Under the 1997 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:

The 1995 documentation guidelines do not specify the type or number of vital signs that count toward "taking vital signs," but you need only one vital sign from the list above to count as one bullet and satisfy the vital signs credit for a 1995 physical examination.

Ancillary staff (for example, a nurse) may measure and record the vitals.