Wiki Billing an E/M without vitals

[bleap]

We have had some issues with our EMR and have some visits where the vitals were not retained. Can we still bill these visits?

 

[csperoni]

Why do you believe vitals are required to bill a visit? Current E&M guidelines are to code by MDM or time.
"E/M codes that have levels of services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination are determined by the treating physician or other qualified health care professional reporting the service. The care team may collect information, and the patient or caregiver may supply information directly (eg, by electronic health record [EHR] portal or questionnaire) that is reviewed by the reporting physician or other qualified health care professional. The extent of history and physical examination is not an element in selection of the level of these E/M service codes."