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Wiki Level IV requirements of vitals

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twosmek

twosmek

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Does anyone know if vitals are required to be recorded to bill a level IV new pt or consultation visit. This is for an orthopedic practice.
 
If you are using the single system exam from 97 guidelines, yes the vitals are required. If you are basing the level on time, then no vitals are not required.

Laura, CPC
 
They aren't required if you are meeting the exam level in other areas using the 95 or 97 guidelines for the level of service you are billing. There aren't any exam portion - body or organ systems - that are required. It should just be an exam that is medically necessary for the presenting problem.
 
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