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Evaluation Code

  1. #1
    Smile Evaluation Code
    Medical Coding Books
    If vitals were not taken during a particular visit would you still be able to consider an E & M code? I guess what I'm is can you still charge a evaluation code if vitals were not taken?

  2. #2
    Duluth, Minnesota
    short answer - yes

    you can charge an E/M even if vitals aren't taken. Vitals are a "bullet" not a requirement. As long as documentation supports the 3 components of an E/M you can bill/code the E/M. Vitals aren't "always" taken. Other "bullets" are/can be marked under each component. (several to choose from)
    Donna, CPC, CPC-H

  3. #3
    I agree with dmaec.

    However, if you do check the vitals, to meet the bullet requirement you must have 3/7 vital signs.

  4. #4
    Milwaukee WI
    Default 99211
    99211 requires only a chief complaint. I know, everyone calls this a "nurse visit" ... but it can be coded for services provided by a physician, NP or PA (I'd talk to them about documentation and leaving money on the table if all they're giving me is a Chief complaint ... but that's another story.)

    I also agree with Donna and AR ... vitals are just one of the bullet points in the exam. As long as you meet the required # of bullet points (in any combination) you can determine your level of exam, and code your E/M.

    F Tessa Bartels, CPC, CEMC

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