tci ED Coding & Reimbursement Alert - 2001 Issue 12

Reader Question: Vital Signs by Nurse

Question: Can vital signs recorded by a nurse be counted as part of the physician exam if the emergency physician does not specifically reference them in his notes?Louisiana Subscriber  Answer: ED physicians are compensated only for services they perform not for services provided by hospital staff. However, the physician can review the vitals and incorporate this information into the physical evaluation. In this instance, the information is considered to be part of the physician examination, albeit recorded by ancillary staff. It may then be factored with other aspects of the exam when determining which level of service...

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