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.
Debunking the myth
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.
Background
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 LOS no longer depends on the breadth of documented history and examination.
Takeaway
The number of vital signs recorded during an outpatient visit does not impact the LOS which may be billed. Only the medically necessary and appropriate history and examination should be included, thus reducing documentation burden.
Resources
- Interactive AMA Resources Providing Guidance on how to Implement 2021 E/M Coding Changes (2023 Updates). Accessed July 2025.
- 2023 AMA Evaluation and Management (E/M) Services Guidance (PDF). Accessed July 2025.
- 2023 Simplified Outpatient Documentation and Coding STEPS Forward Toolkit. Accessed June 2023.
- 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.
- 2021 Physician Fee Schedule Payment for Office/Outpatient Evaluation and Management Visits Fact Sheet (PDF). Accessed August 2023.
- Download this myth: Does the number of vital signs recorded affect billing? (PDF)
References
- 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
Debunking Regulatory Myths overview
Visit the overview page for information on additional myths.
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. Additionally, all applicable laws and accreditation standards should be considered when applying information to your own practice.
