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Thread: Vital Signs - Documentation

  1. #1
    Join Date
    Apr 2007

    Default Vital Signs - Documentation

    AAPC: Back to School
    Looking for clarification on vital signs -

    One of our locations has been taking vital signs on every patient on every visit (to include Pulse, Weight, Blood Pressure and Temp) - does this need to be done on every visit for billing purposes?

    Thanks, Lori

  2. #2
    Join Date
    Apr 2007


    If the doctor is using that as an element of exam for their E/M leveling, then yes you would need at least 3 documented and pulse ox doesn't count (per 97 DG).

    I would think this would be up to the provider. If they feel it is necessary it should be done regardless of how it affects billing.

    Laura, CPC

  3. #3


    3/7 vitals counts as a "bullet" for the 1997 guidelines for constitutional.
    For the 1995 guidelines, you could argue a single vital sign documented falls under the constitutional exam.

    It may or may not be required depending on the service you are providing. If you are billing for evaluation & management code, requiring content from the exam, such as a new patient, the vital signs aren't hurting you by doing so-- they are helping support the level of examination performed and documented.

    If the patient is coming in for a procedure, it's not necessarily required from a coding standpoint, but I'd say definitely required from a clinical standpoint.

    Either way you look at it -- the vitals signs are integral to any service provided. They immediately indicate if something is wrong. (most times) My employed physicians are required to document them. (well, ancillary staff) Now if the patient is just coming in to pick up a script or ask a simple question, I don't think I'd throw the blood pressure cuff on them. (unless of course, they are coming in for that reason...so many if's and's or but's... )
    Last edited by ARCPC9491; 06-22-2009 at 08:02 AM.

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