Wiki E/M Physical Exam-Constitutional requirements

[Diana2032]

I’m new to E/M coding and my coworker is telling me that when it comes to the Constitutional Exam NOT only the three vital signs are required but also and evaluation of the patient’s physical appearance (E.g. development, nutrition, body habitus, deformities, attention to grooming, etc). I have been told in the past that it was either or not both. Can someone clarify this for me? Are both required vitals and physical appearance?

Thanks so much!!!

 

[smidge1]

E/M Constitutional

The E/M guidelines do not state that you have to have both; you need to have 3 in that category to meet
the E/M guidelines.

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html

Here is the link to the CMS website for the coding guildelines.

Hope this helps