This resource is part of the AMA's Debunking Regulatory Myths series, supporting AMA's practice transformation efforts to provide physicians and their care teams with resources to reduce guesswork and administrative burdens.
The number of vital signs recorded during an outpatient visit impacts the level of service which may be billed.
In light of the 2021 changes to the outpatient evaluation and management (E/M) coding requirements, the number of vital signs recorded during a patient visit no longer impacts the level of service which may be billed.
In 2021, significant changes to the Current Procedural Terminology (CPT®) Evaluation and Management (E/M) codes went into effect. With the previous standards from 1995 and 1997, there were three main components that contributed to determining the appropriate level of service (LOS): history, examination, and medical decision-making (MDM). For vital signs to count as part of the examination component, three out of seven vital signs had to be recorded.
The 2021 E/M services guidelines were designed to streamline documentation and reduce clinically irrelevant documentation burdens for physicians. This upgrade affects all outpatient visit E/M LOS billing standards. The guidelines provide that documentation for coding and billing purposes be based on either the level of MDM alone or the total amount of time spent providing care for the patient on the day of the visit (including before and after the visit, not just face-to-face time). In other words, determination of the appropriate level of service no longer depends on the breadth of documented history and examination. Only the medically appropriate history and examination should be included, thus reducing documentation burden.1
- Interactive AMA Resources Providing Guidance on how to Implement 2021 E/M Coding Changes. Accessed June 2023.
- AMA Guidance on E/M Office or Other Outpatient & Prolonged Services Code Changes. Accessed June 2023.
- Simplified Outpatient Documentation and Coding STEPS Forward Toolkit. Accessed June 2023.
- CPT Evaluation and Management AMA Microsite. Accessed July 2023.
- Debunking Regulatory Myths Fact Sheet: Documenting Time for Each Task During Outpatient Visits. Accessed July 2023.
- Physician Fee Schedule Payment for Office/Outpatient Evaluation and Management Visits January 2021 Fact Sheet. Accessed August 2023.
- Download this myth: Impact of Vital Signs on Level of Service Billed (PDF)
- AMA STEPS Forward®. Simplified Outpatient Documentation and Coding Toolkit. Published online August 2022. Accessed July 6, 2023. https://www.ama-assn.org/practice-management/ama-steps-forward/simplified-outpatient-documentation-and-coding-toolkit
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Disclaimer: The AMA's Debunking Regulatory Myths (DRM) series is intended to convey general information only, based on guidance issued by applicable regulatory agencies, and not to provide legal advice or opinions. The contents within DRM should not be construed as, and should not be relied upon for, legal advice in any particular circumstance or fact situation. An attorney should be contacted for advice on specific legal issues.