Wiki Vital Signs Documentation

[dcarr]

The 1997 E&M Guidelines state that vital signs (a minimum of 3) may be documented by staff and counted as one bullet in the contitutional physical exam section. This comment is not stated in the 1995 guidelines. Since constitutional isn't a listed body system in the 1995 guidelines, are staff documented vital counted in the ROS when using 1995 guidelines?

 

[Cottrell]

In the 1995 guidelines constitutional is an organ system. Vital signs would count toward organ systems.

 

[dcarr]

I see in the 1997 Guidelines where it states staff can document the vitals and it count in the physical exam section but I can't find that same state regarding the 1995 guidelines.

 

[LLovett]

I think the info you are looking for is on page 9, where they define the organ systems.

http://www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf




Laura, CPC