E&M audit question

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I would like to ask a question about audits. If the Dr. dictates, under the exam portion, that the patient appears comfortable and in no apparent distress, could you count this as psyche? Would like to know what everyone thinks about that.

Thanks for your input.

Monica
 

ARCPC9491

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I would like to ask a question about audits. If the Dr. dictates, under the exam portion, that the patient appears comfortable and in no apparent distress, could you count this as psyche? Would like to know what everyone thinks about that.

Thanks for your input.

Monica
This would be constitutional as the provider is commenting on the patient's general appearance.

If they said:
Patient is comfortable, no apparent distress, alert and oriented X 3. - This would be constitutional and psych. (Oriented X 3 means orientation to time, place, person.)

Other items for psych would be commenting on patient's judgement and insight, orientation to time, place, person as mentioned above, recent and remote memory, and mood and affect.

Hope that helps :)
 
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ARCPC9491

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pleasant or happy? psych or constitutional??
Pleasant could go either way - it can be characterized by manners, behavior, or appearance. To me, unless the provider states something other than just "pleasant" I would leave it as constitutional.

Normally they say, "I had the pleasure of meeting w/ Ms. Jane Doe who is a pleasant well developed, well nourished female in no acute distress..." or something to that affect. In that example, that whole sentence I would count as constitutional.

Happy is a mood, so I would go with psych for that.:)
 
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