Wiki 1997 Multisytem Exam Psych elements

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tjbd57

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Help!!!
I usually audit E/M services using the 1997 guidelines for specialties only and mostly use 1995 for all other clients, especially Hospitalist services. Recently I have been assigned to a client that uses the 1997 guidelines for all services and there has been a disagreement of how many bullets are counted for the statement "alert and oriented x 3" for PSYCH in the exam. Would this statement count as 1 bullet or as 2 bullets? It is causing a difference in the level of E/M from coder to auditor and we cannot seem to come to an agreement. Can someone please help solve this so we can come to terms with it and be on the same page moving forward? References to back up the correct determination would be greatly appreciated as well:)
Terri Durham, CPC
 
If "oriented x 3" counts as 1 bullet are you saying that "alert" is counted as one bullet independently as well?
Thank you
 
For which element of the 1997 Psych exam are you counting "alert" ? I would only consider it as either part of general appearance or orientation. Does the note contain other comments on appearance? If so, then no additional credit would be given for this observation.
 
General appearance states "no apparent distress" and Mental status states "Alert and Oriented x3. I think you just answered the question and I appreciated your help very much :eek:
Terri
 
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