Psychiatry Coding & Reimbursement Alert

Published on Wed Jul 04, 2012 PDF

Question: I am reviewing some charts for Psychiatry. The psychiatrist is stating "alert and oriented times three" is neurological, and the coder states they count it under psychiatric. How is everyone else counting this?

Arizona Subscriber

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. The 1997 E/M documentation guidelines count it under the psychiatric portion of a general multi-system exam, as brief assessment of mental status, including orientation to time, place, and person, along with recent and remote memory and mood and affect. In any case, the important thing is not to count it twice as both neurologic and psychiatric.