What are the requirements for documenting vital signs (blood pressure, heart rate, respiratory rate, O2 saturation, temperature, height, and weight) for ophthalmic visits; eye visit and evaluation and management (E/M) codes? Do they differ by state or apply nationwide?

Answer:
Neither E/M nor eye visit codes require documenting blood pressure, heart rate, respiratory rate, O2 saturation, temperature, height, or weight. This information may be medically relevant in treating the patient and the physician can request that it be documented in a patient's history. Facilities may require documenting certain vitals per their protocols, but they are not required for coding purposes. There may also be Merit-Based Incentive Payment System (MIPS) measures that you are reporting which require documenting these vitals but again, not required for coding E/M or eye visit codes.

E/M codes require a medically appropriate history and examination, and eye visit codes require a history (not defined), general medical observation (not defined) and chief complaint. E/M codes are determined by overall medical decision making or total physician time and eye visit codes are determined by exam elements documented as medically relevant to perform.

Find comprehensive education on E/M and eye visit codes in Fundamentals of Ophthalmic Coding.