Do you need three vital signs for it to count?

March 4th, 2009 - Codapedia Editor
Categories:   Audits/Auditing   Evaluation & Management (E/M)  
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This is one of the most common questions physicians and NPPs ask at coding conferences.  Do I need to document three vital signs for it to count.

It depends on which set of guidelines the clinician is using.

For 1995, no. Any one vital sign or general appearance counts for constitutional.

For 1997, yes. There must be three vitals documented in the record, recorded by the clinician or the ancillary staff.

The 1997 Guidelines read:

Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration 5) temperature, 6) height, 7 weight (May be measured and recorded by ancillary staff)

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