HNS Policy 

 

Vital signs must be obtained as part of every examination for which an evaluation/management (E/M) code is billed and results must be documented in the healthcare record. 

 

Mandatory vitals include: 

  1. Weight

  2. Pulse Rate

  3. Blood Pressure

  

Other vitals may also be appropriate but are left to the discretion of the physician, but should always be consistent with the level of examination performed.

 

When a new patient presents requesting only maintenance care, vitals must be taken as part of the initial evaluation.  The physician may exercise clinical judgment as to the frequency of repeating them.