Results 1 to 4 of 4

Documentation of vitals in exam

  1. #1
    Default Documentation of vitals in exam
    Medical Coding Books
    Is it ok to say vitals are stable? Is this countable on the audit sheet using 95 guidelines?

  2. #2
    That would be counted as constitutional, but what is considered stable would be the problem, did the physician want pt to return for BP check? It would be safer to document that. Vitals stables is like stating all other systems negative, but that is what the physician would document. If the nurse or medical assistant is doing the vitals these should be documented.
    Kiana CPC, CPC-H, BCS-M, BCS-R

  3. #3
    I would count vital signs stable as constitutional for 95.

    For 97, you'll need to specifically state 3/7 to get credit.

  4. #4
    North Carolina
    I agree. I asked a similar question on another forum and was reasurred with this excerpt. In your case, stable=normal (In my opinion).

    From p. 10 of the 95 guidelines:

    ●DG: A brief statement or notation indicating "negative" or "normal" is sufficient

    to document normal findings related to unaffected area(s) or asymptomatic

    organ system(s).
    Rebecca CPC, CPMA, CEMC

    Your click COUNTS...

    CLICK to give FREE mammograms!

Similar Threads

  1. Vitals Documentation
    By cwilson3333 in forum E/M
    Replies: 2
    Last Post: 10-15-2013, 05:41 PM
  2. Vitals - Do vitals have to be taken
    By cwilson3333 in forum E/M
    Replies: 2
    Last Post: 11-06-2012, 01:53 PM
  3. Vitals by RN
    By sparkles1077 in forum E/M
    Replies: 3
    Last Post: 10-19-2010, 02:14 PM
  4. Vitals - We are currently going to EMR
    By proverbs in forum Auditing General Discussion
    Replies: 4
    Last Post: 04-21-2010, 02:56 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.