Approved elements for ros/exam components

[REGINALD068]

Good afternoon
Can someone please confirm if vital signs are an approved/qualified element of E/M?

Thanks

 

[Pathos]

Hello,

Absolutely, Vitals are a common component of the Physical Examination (Constitutional).

From CMS E/M Guidelines:

"For purposes of examination, the following organ systems are recognized:
Constitutional (e.g., vital signs, general appearance)"

"Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)"

As stated above, documentation would need to show at least 3 of the above 7 vital signs in order to count towards credit.

Hope that helps!

 

[REGINALD068]

Yes....I've advised the Providers they can include the findings of vital signs under those elements, but the argument is, vitals can be listed separately and counts towards required elements: BP, HR, Temp - will count as three elements met. This is incorrect. Yes? But if the Providers list them as findings under the correct element, that is acceptable. Yes?