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Thread: Exam help Please!!

  1. #1
    Join Date
    Apr 2007

    Default Exam help Please!!

    AAPC: Back to School
    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
    Join Date
    Apr 2007
    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
    Join Date
    Apr 2007


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

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