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In this month's coding column, our expert answers whether or not you need to include vitals when coding a patient encounter.
Q: We saw a patient today and it appears that the vitals we entered were not saved to the system and we are unable to recall what the actual vitals were, I know that vitals are important to being able to bill for a visit, is there a way that we are able to document that the vitals are lost and if so, are we still able to bill for the visit?
A: Most E&M visits beyond a 99211 include the ‘constitutional’ or ‘general’ system on exam, but they don’t have to. Primary-care physicians document principally under the 1995 documentation guidelines - which are at the organ system level. So comments such as 'ill appearing' or 'well-appearing NAD' count as constitutional - you don't actually need vitals.
It is likely that your docs typically document well-enough that one minor miss like this wouldn't impact coding. Just to be thorough, and from a risk management perspective, the MD may wish to add an addendum that for some reason vitals were not recorded but that there were no major concerns.
Q: Are “vital signs” required to bill a 99211 for in-office [Internationalized Normalized Ratio] check?
A: CPT code 99211 is the only code in the office or other outpatient setting category with no specific documentation elements for the extent of history, examination, and medical decision-making required. We really just need to see an indication that the MD was involved in the decision-making typically associated with review of meaningful information obtained by nursing or other staff.
Anything to the contrary probably stems from the old 'nurse visit' mythology; that it's about what the nurse does, which usually includes vitals. It’s not about what the nurse does – it’s the MD review of data and any subsequent management that you are getting for.
Q: I was wondering if you could give me any guidance about using time for coding when the time is 20 minutes, since that is exactly between the 15 minute/99213 and the 25 minute 99214? I am running into this quite often because they have changed most of my appointments to 20 minutes and there are times where the patient is fairly stable with [for example] two problems and doesn’t require a medication change, so I would normally put 99213. However, there may be something requiring discussion that extends the appointment to 20 minutes.
Example: this morning I had a female patient who is getting ready to start having a family in upcoming months so we discussed medications vs no medications in pregnancy, how we could taper her, etc. It was 20 minutes on the dot.
A: The bad news is that Medicare has pretty clearly said that the 'midpoint' rule - meaning more than halfway between two time listed as below qualifies you for the higher code - does not apply to the E&M codes.
So if your practice is using the more conservative Medicare guidance for all patients, then the mid-point isn’t much use for E&M codes. The AMA and the CPT manual endorse this - Medicare specifically doesn't. So at least for Medicare/Medicaid and TRICARE - if you are between two 'typical' times you have to use the lower. For commercial payers you could go with the midpoint (i.e. 21 minutes is enough for a 99214). But that said, 20 minutes on the dot will still fall to a 99213 every time if you are coding by time.
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