Vitals missing on EM

taniafrost

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If vitals are missing from the EM can the claim still be billed, if so does it effect the level of coding?
 
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Congers, NY
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Hi Tania,

There are other elements to consider when billing the evaluation management level of service.

It is the decision of the physician depending on the reason for the visit.

Not having vitals shouldn't be a reason to not bill for the visit. Some visits , like counseling may not require them per the decision of the physician.


Hope this helps.

Julie
 
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Pbhatt1

Networker
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Valrico, FL
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Vitals

Very important to be rocorded under E/m note for the patients who are receiving treatment for certain diseases. Per changes made by CMS in 2015. E.g.- through vitals provider can measure certain specific comorbidities related to the diseases. Obstructive Sleep Apnea Dx requires obesity level and that done through vitals (height, weight , temperature). It depends on specialty of practice.
 
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