Exam documentation - I know that VS can be counted as constitutional


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Hello everyone,

I code E/M for ED providers, and I have a question about exam documentation. Occasionally, for whatever reason, the exam portion of our notes will be blank, with the exception of the vital signs. I know that VS can be counted as constitutional, but is that a billable service? According to both 97 and 95 guidelines, a problem focused exam contains an exam of the affected body areas or organ systems. For example, if a patient comes in for dental pain, and the exam only has the vitals, can that E/M even be billed? I would appreciate any sources where I can see what the CMS says about this, as the guidelines are all I can find. Thank you all, and have a wonderful day!


True Blue
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If only vital signs are documented it's theoretically billable as a single system exam, but personally, I would query these records back to the provider. Especially given that it's an emergency room setting, I would consider a note that's missing a problem-appropriate PE to be incomplete.