Using Vital Signs for Examination or Review of Systems
Published on Wed Jan 01, 2003
A few readers have asked for clarification of a coding tip that appeared as part of the article "Top-Ten Coding Tips for Ob-Gyn" in the July 2002 Ob-Gyn Coding Alert. The information in this article came from a panel discussion session at the Coding Institute's National Conference on Obstetric and Pediatric Coding in December 2001. In Tip #1, Philip Eskew, MD, medical director of infant and women's services at St. Vincent's Hospital in Indianapolis, states that physicians should document height, weight and blood pressure. Some readers thought the tip implied you could use these vital signs for both an examination element and for a review of systems. Although the first two sentences explain that you can use these vital signs for either purpose, the rest of the explanation talked about the review-of-systems use. To clarify the issue, although a nurse may take a patient's vital signs, the signs can be counted toward only one area of the documentation criteria. That is, the physician can count the vital signs toward meeting the examination criteria, or the physician can use the vital-signs information as part of the review of systems, but not both.
Before you can count vital signs as part of the review of systems, however, the physician must comment on the system being reviewed. For instance, if the patient's weight indicates a weight gain, the note must specifically mention this to be counted as a review of systems. For most physicians, using the vital signs as a way to elicit information during the review of systems is not their usual manner of documenting.
If an auditor sees only vital signs on the record, they will be counted as an examination element unless the physician has clearly used the information as part of a review of systems. The auditor will not give the physician credit for both an examination element and a review of systems.
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