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Rules on the Consitutional part of the Exam

  1. #1
    Default Rules on the Consitutional part of the Exam
    Medical Coding Books
    I need a confirmation on the constitutional part of the Exam. Are three vitals necessary to be documenated plus the general appearance? Or does the three vitals only need to be present? I have searched and searched for an answer on this, but all I have been able to come across is the Documentation Guidelines of Constitutional: At least three vitals and General Appearance. I can't find anywhere that specifically states that the General Appearance is a requirement.

    Can anyone help with this or give me a reference if they have one? Thank you!

  2. #2
    1997 DG allow for 2 bullets under constitutional. If you only get 3 vitals, that is one bullet. If you only get general appearance, that is one bullet. You do not have to get both in order to get credit.


    Measurement of any three of the following seven vital signs: 1) sitting or standing blood
    pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5)
    temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)

    General appearance of patient (eg, development, nutrition, body habitus, deformities,
    attention to grooming)

    Laura, CPC

  3. #3
    1995 has no rules. It's very much subjective. (however, it is good to compare to 1997)

    One vital sign could count as a check mark in constitutional and that's all you need.

    It all boils down to the power of the argument, if audited.

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