tci E/M Coding Alert - 2013 Issue 2

Reader Question: Vitals Aren't Critical to Code Choices

Question: A daughter brought her mom to our office. The mother was seen by the doctor, but he didn’t take any vitals (it was after normal office hours and the nurse was gone for the day). He documented the office visit for this “no appointment add on” service, but thinks we can’t bill for the encounter since we didn’t take vitals. He did document everything else (history, exam, medical decision making). I think we can bill for the visit, but can’t find documentation supporting my opinion. Who’s right? Minnesota Subscriber Answer: In this...

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