Wiki Physical Exam: Counting Constitutional as extended

[fjohnso6]

Good afternoon all,

When counting systems for a detailed level physical exam according to the 1995 Documentation Guidelines, does anyone count constitutional as extended if the provider examines and documents general appearance and at least 3 vital signs?

Thanks.

 

[FTessaBartels]

Is it the AFFECTED organ system?

For a DETAILED exam under the 1995 guidelines you need an expanded exam of the affected body area or organ system, plus other related or symptomatic systems. So you first have to determine whether "constitutional" is your affected organ system.

If your affected organ system is "constitutional" then I'd expect more than just listing the vitals.

For example if the chief complaint is weight loss ... an expanded exam of the constitutional system might look like this example: thin 30 YO Female, NAD, Ht 5'6", Wt 103 lb (vs 110 lb last week), BP 120/60 (stable from previous visit), temp 98.6 (normal), alert, conversant, cooperative

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[fjohnso6]

What if it is a related system

Thank you, the response helped clarify.

What if constitutional was documented in the way you described but it was not the affected body area but was related to the effected body area?

 

[FTessaBartels]

1995 guidelines

Read the descriptions again for the 1995 guidelines. The EXPANDED exam MUST be of the AFFECTED body area or organ system.

If your chief complaint was "sprained ankle" and you had the same expanded exam of the constitutional system, but only "right ankle swollen" then you would NOT have a detailed exam per 1995 guidelines.

Hope that helps.

F Tessa Bartels, CPC, CEMC