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tci E/M Coding Alert - 2013 Issue 5
Reader Question: Identify 3 'Vitals' Before Adding to Exam
Question: Would you please explain how taking the vital signs contributes to determining the E/M service’s physical exam?
Georgia Subscriber
Answer: Checking any three vital signs will count as one bullet in the physical exam, based on the current (1997) documentation guidelines for E/M services, which you can find at (www.cms.gov/MLNEdWebGuide/25_EMDOC.asp).
Here’s how it works: Under the current 1997 documentation guidelines for E/M services, performing (and documenting) any three of the following seven vital signs will count as one bullet in the constitutional system/body area of the general multisystem examination:
1. Sitting or standing...
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