Billing for Vitals Recordings

November 19, 2010

Billing for medical assistant's work

Question: I am in a psychiatric practice that wants to begin having an MA do weight and blood pressure recordings, along with lancet diabetes testing at each visit. How do I code and bill for this service? Also, where will I find the OSHA regulations for these services?

Answer: Weight and BP are just part of vitals and are part of an E&M if you are billing those types of codes. If you are using counseling or medication management codes, then this is simply an additional service for which there is no separate reimbursement.

I’m not sure I understand the role of the diabetic testing in your practice, but you need to look at the CLIA-waived tests for compliance here. OSHA is not relevant here. If anything, depending on the place of service - hospital outpatient versus free-standing clinic - you may need to check JCAHO regulations. You can find these online at jointcommission.org.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or physicianspractice@cmpmedica.com.

This question originally appeared in the March 2010 issue of Physicians Practice.