Myth or fact? The number of vital signs recorded affects billing

Andis Robeznieks , Senior News Writer

There are some physicians who believe that the number of patient vital signs recorded during an office visit affects the level of service that may be billed.

The truth is, however, that ever since changes to the documentation guidelines and related.

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Current Procedural Terminology (CPT®) codes for outpatient evaluation and management (E/M) services were instituted in 2021, the number of vital signs recorded during a patient visit no longer influences the level of service that should be billed.

The AMA is spreading this message as part of a series of “Debunking Regulatory Myths” articles that provide clarification to physicians and their care teams in an effort to reduce the administrative burdens that divert doctors’ attention from the delivery of patient care.

“Determination of the appropriate level of service no longer depends on the breadth of documented history and examination,” the AMA explainer says. “Only the medically appropriate history and examination should be included, thus reducing documentation burden.

The misconception stems from now outdated standards for documenting and coding E/M office visits. The 2021 E/M reforms were developed by the AMA, adopted by the Centers for Medicare & Medicaid Services, and replaced standards that had been in effect for more than two decades. The AMA led a coalition of 170 state and specialty medical societies to simplify coding and documentation requirements and make them more clinically relevant.

The changes were also intended to provide opportunities to refocus attention on patient care by reducing administrative burdens.

They included providing physicians and other qualified health professionals the flexibility to select a level of service based on either the complexity of medical decision-making or total time on the day of service—including work completed when the patient wasn’t present.

The new E/M office visit code-selection criteria removed complex counting systems that sometimes varied by payer. 

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Under the previous standards that were adopted in 1995 and 1997, there were three main components that contributed to determining the appropriate level of service:

  • History.
  • Examination.
  • Medical decision-making.

For vital signs to count as part of the examination component, three out of seven vital signs had to be recorded.

The AMA explainer outlines a number of resources available to help set the record straight on E/M documentation and coding, including an AMA Private Practice Simple Solutions webcast that provides a review and explanation of the 2021 changes (registration required).

Earn CME credit; submit a question

Learn more with the “AMA Debunking Medical Practice Regulatory Myths Learning Series,” which is available on AMA Ed Hub™ and provides regulatory clarification to physicians and their care teams. For each topic completed, a physician can receive CME for a maximum of 0.25 AMA PRA Category 1 Credit™.

Physicians are encouraged to submit questions or ideas they have about potential regulatory myths. The AMA’s experts will research the matter. If the concern turns out to be a bona fide regulation that unnecessarily burdens physicians and their teams, the AMA can get involved and advocate for a change in the regulation.