Wiki Vitals for E/M

[CRegister]

How many vitals are required to code E/M levels with the new guidelines?

 

[TTcpc]

Since the 2021 E/M updates only a medically necessary/pertinent history and exam are required by the provider. Vitals would fall under the exam. It would depend on what the patient was being seen for and whether the provider felt the vital signs obtained were necessary for their medical decision making for the visit. For example, a cardiologist would be interested in BP, HR and even respiratory rate, whereas a ortho provider might not necessary need any vital signs for the patient to treat a fracture. This is from the AMA 2023 guidelines: "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"