tci Part B Insider - 2011 Issue 45

Reader Question: 1 Exam Bullet May Require 3 Vitals

Question: Can you please explain how taking the vital signs contributes to determining the E/M service's physical exam?New Hampshire SubscriberAnswer: Checking any three of seven 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 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 blood pressure2...

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