Three Vital Signs

[Sushirolls]

---

Members do not see this ad.

I've been weighing, and doing pulse oximeter for my three.
Contemplating the BP.
Any experience or recommendations for an outpatient psych office?
Not too excited about having multiple cough sizes and doing auscultation myself with the ol' sphygomometer.

*Three vital signs are needed for certain levels of E&M documentation to support certain billing/coding.

 

[MBBSMOM]

I don't do outpatient but you can easily buy an automatic BP machine. Some are very inexpensive 20-30 dollars. The ones used in hospital/clinics are usually around the 300-1000 dollar range.

 

[Sushirolls]

I'm hoping for details like specific brands or even model numbers from folks. Then details on how well they hold up, nuances of operation, validity of read outs, price points, etc

 

[Jules A]

I use a Welch Allyn 4200B I got off ebay for $300. It came with adult and large adult cuffs and I ordered an additional kids cuff-new for $18. It was an older model but new in box. In addition to billing I believe a reasonable standard of care. When I get readings that are elevated, not due to meds I'm prescribing, I document they were given the results and recommendation to follow up with PCP.

 

[Sushirolls]

Are you getting fair congruence from patients who just saw their PCP or other doctor? I.e. 120/75 at PCP yesterday, you get 118/78? Or getting feed back, like huh, wasn't that earlier today at Cardiologist office?

So far I'm pretty happy with my scale, not hearing too much patient grumbling besides the act of a weight itself.

 

[Jules A]

Its a mix and there are always some who insist their BP is never that high anywhere else which I figure is either white coat syndrome or they are trying to avoid a discussion on the ills of HTN. With this machine there seems to be a reasonable variety of readings, more patients are in agreement than not and my own blood pressure is what I would anticipate. I don't expect a table top model to be as accurate as one of the more expensive hospital units but I also didn't want the $20 home-wrist version.

 

[SourceOfDenial]

Why are you checking pulse ox? How often do you find hypoxia?

 

[Sushirolls]

So you're happy with it, not looking to change up device?

 

[Sushirolls]

Why are you checking pulse ox? How often do you find hypoxia?

It comes with the pulse. Pulse-oximeter, they're called.

It gets me three vital signs.

 

[Orgone]

I use an Omron automatic BP from Costco, was $40-50. Like with Jules' experience, a fair percentage swear it's never as high as I measure. But I take it on myself and it's consistent with itself and my other readings.

 

[whopper]

I use a Veridian BP monitor.
Costs about $55.

The main gadget thing itself has a lifetime guarantee, but the cuff doesn't. Cuffs will last you about 1 week to 2 years. Yes I've had them last literally about 1 week before they puncture.

Takes about 30 seconds to get BP and HR and far faster than manually doing it.

RECOMMENDATION: DO NOT GET ONE OF THOSE WRIST BP CUFFS. They work using infrared and the wrist's relation to the heart. Depending on the patient the position of the device is unique depending on their size and the size of their heart. It's great if it use it yourself cause after if you've gotten it a few times muscle memory takes over and you don't have to fidget around trying to get it to work. But when you use it on patient to patient to patient you'll spend more than 5 minutes each trying to position it right.

 

[SourceOfDenial]

I mean, if you’re doing it simply to satisfy e&m codes as sushi is saying, does the number even matter?

Why not just count respirations?

 

[Sushirolls]

I mean, if you’re doing it simply to satisfy e&m codes as sushi is saying, does the number even matter?

Why not just count respirations?

Because you already have the third vital sign with the oximetry, and you don't need to stare or indirectly stare and count chest rise for 30-60s. As a general rule, I think not staring at my patients chest is a good thing.

But yes, Pulse, Resp, weight would be more traditional then pulse ox.

 

[Armadillos]

Doesn’t it have to be medically necessary to fulfill the requirements? You can’t just do extra non medically necessary stuff for the hell of it to bump up your billing. Seems tough to justify pulse ox in outpatient psych as medically necessary except in a few pretty uncommon hypotheticals.

 

[Sushirolls]

This is part of the problem with Psychiatry being brought into the E&M fold. And the metrics of billing requirements. Resp isn't really med necessary for most patients, nor is BP, nor weight, nor height. But you can stretch your mind enough and think of many differentials where it might be worth having. Most primary care clinics don't pay attention nor do they apply this heightened 'medically necessary' concern you are raising to the task of some type of vitals. Countless times I've gone to a primary care office for a nursing visit or very low level issue and yet, my BP, Height (unchanged), pulse, resp, Temp, and even pulse ox are all taken and having nothing to do with the CC.

The billing is already appropriately for a level XYZ, but because the goat rodeo requires it, I document three vitals to ensure its not a reason to deny/down code the work I've done. I'm not leaving that to chance.

Many of my patients smoke. Many of my patients have CNS suppressing medications, many of my patients have OSA, many of my patients are geriatric and at risk of MI/CVA/onc related DVT with emobolism. Documenting pulse ox is justifiable as routine part of my clinic when considering overall population served

Moving on, from this side show, back to the thread topic at hand.

 

[Armadillos]

Although more relevant, why do you even need vitals to get the code you want? Is it just for 99215s?

 

[Sushirolls]

Its been years since I've looked closely at the implications of vitals. I believe they are part of the exam and nothing more than an additional bullet point. Three vitals means it counts. Less than three means it doesn't. I believe if you want that as a bullet point for the billing levels, its pertinent for level 2 thru 5. I rarely bill 99215, probably 0-5% of my claims

Some one else correct me if I'm wrong.

 

[downwithDTB]

Its been years since I've looked closely at the implications of vitals. I believe they are part of the exam and nothing more than an additional bullet point. Three vitals means it counts. Less than three means it doesn't. I believe if you want that as a bullet point for the billing levels, its pertinent for level 2 thru 5. I rarely bill 99215, probably 0-5% of my claims

Some one else correct me if I'm wrong.

My understanding is that either: (the history or exam has the 215 bullet points AND the complexity meets 215) OR (the history AND physical of 215 detail were medically necessary in spite of lower complexity). In the later case I believe you would need and document a real reason for checking the pulse ox (i.e. copd and c/o SOB, not just stable without complaint) or BP (monitoring med side effect).

 

[Armadillos]

Its been years since I've looked closely at the implications of vitals. I believe they are part of the exam and nothing more than an additional bullet point. Three vitals means it counts. Less than three means it doesn't. I believe if you want that as a bullet point for the billing levels, its pertinent for level 2 thru 5. I rarely bill 99215, probably 0-5% of my claims

Some one else correct me if I'm wrong.

Yeah if you have 3 vitals it counts as one point of examination. But even for a 99214 level exam you only need like 9 points which MSE gets on its own but if you want even more can check muscle tone and gait.

I could be wrong but I believe you can get any code except 99215 w/o vitals

Edit - checked again and looks like comprehensive exam (which requires vitals) is not even required for 99215 if you have comprehensive history taking and high medical decision making, so best I can tell vitals not technically required for any code 9921x.

Although I’m not an expert so curious to hear if I’m understanding wrong

 

[285963]

You need at least 6 exam bullet points for 99213 and at least 9 exam bullet points for 99214, assuming that you don't meet criteria in the subjective section. It is not necessary to obtain or document vitals signs for 99213 or 99214, though they can be one of those bullet points if you choose.

https://www.aacap.org/App_Themes/AACAP/docs/clinical_practice_center/business_of_practice/cpt/EM_Coding_SUmmary_Guide_v2.pdf

 

[285963]

You could potentially even bill a 99215 without vital signs if you meet criteria in the subjective section (extended HPI, complete PFSH and complete ROS) and high complexity MDM.

Vital signs are probably most important for the initial encounter. You'd need them to bill either a 99204 or 99205. I'm actually not sure whether you would need them for a 90792--If someone knows, please share.

 

[romanticscience]

You need all three sections for 99204/99205.

I only get vitals at the initial visit for this reason. My automatic BP cuff assesses pulse regularity. So my vital signs are: BP, Pulse rate and regularity, and respiratory rate.


Sent from my iPhone using SDN

 

[Mad Jack]

We usually just do 90792s without vitals, if we need vitals that would be great to know (though I take vitals regularly anyways because I'm particular)