Wiki Documentation Friends

There is a case where multiple providers stated that VSS are not needed to be documented on notes and that it only needs to be documented x amount of times per year according to CMS. The time of the care in question was from 2019. Where can I look up for those guidelines regarding documentation. HHS? OIG? or CMS?

E/M codes do not require documenting vitals. This information may be medically relevant in treating the patient and the physician can request they be documented in a patient's history. Facilities may require documenting certain vitals per their protocols, but they are not required for coding purposes. - Check with your facility policies. 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 visit codes. - Check with your MIPS team, if you have one.

It's expected that any medically relevant information to treat the patient should be documented for that visit. What is their specific objection to doing so?

As JDACPC says above, several common MIPS (and HEDIS) measures are triggered by recording the vitals. Example, BMI and follow-up. The denominator is "adult patients with an encounter" and the numerator is "BMI is recorded for the visit and a follow-up plan is documented for patients outside normal parameters." If there's no BMI for the visit, that's considered non-compliant and counts against you.