Wiki E/M visit without vital

[mracioppi]

Can anyone tell me if an E/M visit can be billed if the patient's vital were taken but not documented at the TOS? The claim has already been billed to a commercial insurance co.

 

[GaPeach77]

It depends on which level you billed.

Simone

 

[mracioppi]

It depends on which level you billed.

Simone

It was a level 4 E/M

 

[kissie]

I am assuming you are talking about the physical exam portion. If you have enough bullets in the physical exam to cover a level 4 you should be fine, you don't have to have the constitutional points to get a four as long as there is enough others mentioned to cover.

 

[mracioppi]

I am assuming you are talking about the physical exam portion. If you have enough bullets in the physical exam to cover a level 4 you should be fine, you don't have to have the constitutional points to get a four as long as there is enough others mentioned to cover.

Thanks, but I was talking about if when the nurse takes the patient's vitals; I was told that if 3 vitals weren't taken by the nurse, like blood pressure, ht/wt and temp, then you can't bill the visit.

 

[FTessaBartels]

1995 vs 1997 guidelines

1997 guidelines require the documentation of 3 vital signs (can be performed by ancillary staff) to get ONE bullet under constitutional.

1995 guidelines have no such specification - even 1 vital sign will qualify as "constitutional." (As will a statement - "well nournished male.")

There is NO requirement that consituttional be one of the systems examined (though it's unusual when it isn't). You simply count up the body areas/organ systems (1995) or the bullets (1997) and determine your level of exam based on what IS documented.

Hope that helps.

F Tessa Bartels, CPC, CEMC