Results 1 to 3 of 3

Vitals Signs: Afrebile. Vital signs unremarkable

  1. #1
    Default Vitals Signs: Afrebile. Vital signs unremarkable
    Medical Coding Books

    (1995 guidelines) Vital Signs stable - count as Constitutional exam? As an auditor, I prefer to have the vitals listed (at least one [i.e. vitals: Temp 98.3...) instead of vitals stable and/or unremarkable. For all of you auditors out there...would you "count" vitals stable??

    P.S. I looked in the forums to see if this has been posted before, but I was not able to find any. If there is one, I apologize in advance =)
    Last edited by 1071471; 06-01-2010 at 05:58 PM. Reason: forgot to mention - 95 guidelines

  2. Default
    For me, I would not give him the bullet. Certainly not under the 1997 and I still would not under the 1995. I consider this very lazy documentation. What vitals? What results?

    "Stable" to me indicates that there is a comparison or a change. Were they unstable and now stable? What and who defines stable?

    If the nurse/tech documented the vitals (BP, temp, HR etc) then I would expect a statement from the physician "vitals reviewed and found within normal limits"

    If he did the vitals himself, then he should specify which vitals and the results

  3. #3
    Milwaukee WI
    Default 1995
    If using 1995 guidelines I would give credit for "Vital signs stable" - AS LONG AS they were recorded somewhere in the chart for that DOS (usually the nurse records).

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

Similar Threads

  1. Vital Signs Required?
    By Cherish79 in forum Medicare Regulations
    Replies: 2
    Last Post: 09-25-2012, 06:04 AM
  2. vitals signs
    By muniasamy in forum E/M
    Replies: 1
    Last Post: 07-07-2012, 05:43 AM
  3. Vital Signs - Documentation
    By lapcpc in forum Medical Coding General Discussion
    Replies: 2
    Last Post: 06-22-2009, 07:56 AM
  4. Vital Signs Documentation
    By dcarr in forum E/M
    Replies: 3
    Last Post: 12-22-2008, 07:26 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.