Results 1 to 4 of 4

Physical Exam: Counting Constitutional as extended

  1. #1
    Post Physical Exam: Counting Constitutional as extended
    New Call-to-action
    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?


  2. #2
    Milwaukee WI
    Default 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

  3. #3
    Default 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?

  4. #4
    Milwaukee WI
    Default 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

Similar Threads

  1. Limited vs Extended Exam
    By chetubig001 in forum Auditing General Discussion
    Replies: 6
    Last Post: 01-13-2016, 01:13 PM
  2. Exam -- constitutional
    By msingh23 in forum E/M
    Replies: 3
    Last Post: 11-07-2014, 11:27 AM
  3. Replies: 3
    Last Post: 09-21-2012, 02:08 PM
  4. Re: Counting Physical Examination
    By medicalsec in forum E/M
    Replies: 0
    Last Post: 07-16-2010, 05:22 PM
  5. NAD: psych or constitutional exam?
    By andersee in forum E/M
    Replies: 8
    Last Post: 01-11-2010, 08:00 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.