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 health care record.
Mandatory vitals include:
- Weight
- Pulse Rate
- 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.