ED Coding and Reimbursement Alert

Question: I am reviewing some charts for Emergency Medicine and the ERMD is stating that alert and oriented times three is neurological and the coders states they count it under psychiatric. How is everyone else counting this?

Answer: It the physician is on record as saying they mean neurologic when they use that documentation notation, then that is how it should be counted. Otherwise, you should look at the presenting problem as a guide for which organ system to place this assessment. For example, if a patient presents with a head injury it would likely count as neurological. However, if a patient appeared to be demented or in a manic depressive episode, it would probably count as a psychiatric element. The 1997 exam guidelines count it under psych, as assessment of mental status along with recent and remote memory and mood and affect.