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Exam help Please!!

  1. #1
    Default Exam help Please!!
    Medical Coding Books
    Under 95 guidelines, if the Physician just says "Vital Signs noted" would you give credit for Constitutional even though the Vital Signs are not actually documented anywhere??

    Thanks everyone!!!

  2. #2
    Kansas City, MO
    Did he document anything else that could be used as constitutional? (Appearance, etc...)
    if not then NO, coders are never to assume. if its not documented, its not done. "Noted" tells us nothing. I would not give credit if I were auditing this.

  3. #3
    I totally agree with that... Thanks, I just needed someone else to say what I was thinking!!! :-)

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