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Exam -- constitutional

  1. Default Exam -- constitutional
    Medical Coding Books
    The following has been document into patient chart for a orthopedic visit, would this qualify for points towards constitutional in the Exam when there was nothing indicate under the exam portion of the chart notes. Appreciate feedback on both as new pt and est. pt.
    Vital Signs
    Height: 67 inches
    Weight: 196 pounds

  2. Default
    I would say no, this would not count as constitutional. For it to count, for either new or established there has to be at least three of the seven options.
    Christopher J. Halk, CPC
    Kunsan Air Force Base
    Republic of Korea

  3. #3
    Default Depends on the guidelines being used
    There are no specified requirements defined in 95 for what has to be documented under the system to get credit for it. So if this was all the documentation you had for a new or established patient, under 95 this would support a problem focused exam.

    I do agree that this would not count under 97 since you are required to have 3 or more vitals for that bullet or a statement regarding general appearance for the other possible constitutional bullet.

    Laura, CPC, CPMA, CPC-I, CEMC

  4. Default
    Thank for your feedback, appreciated

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