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evaluation and management

  1. #1
    Smile evaluation and management
    Medical Coding Books
    Is there anyone out there expected to audit visit documentaion that does not record blood pressure, The doctor refers to vitals being done. Height and weight are being recording in chart but Dr's asst claims no time for blood pressure to be done.
    I have audited 10 charts were visits were already paid at level billed from fee ticket without documentation, during audit I dropped to lower E&M because blood pressure was not done, I also wrote up my findings. I was under the impression that all 3 vitals must be done to count as one bullet. Does anyone know or can anyone clarify this issue for me.


    Let me say thanks ahead of time

    Thelma, alias for Mary K cpc

  2. #2
    Default E&M evaluation
    Thelma,
    You are correct. In order to get credit, 3 vitals must be done and documented.

    Judy

  3. #3
    Location
    North Carolina
    Posts
    3,126
    Default
    That's true for 97 guidelines but not 95.

    97=Constitutional

    1) Three vital signs
    2) General appearance

    95=Organ Systems

    1) Constitutional (e.g., vital signs, general appearance)

    https://www.cms.gov/MLNEdWebGuide/25_EMDOC.asp

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