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Exam ???

  1. Default Exam ???
    Medical Coding Books
    What can i count for this???? On exam the pt is a very pleasnt male. He is alert and oriented times 3 and very cooperative.
    Can i count constitutional and psychiatric?? Thanks

  2. #2
    Central Pittsburgh
    Psych: Pleasant
    Neuro: Awake, alert, and oriented x 3

    Hope that helps.

  3. #3
    Milwaukee WI
    Default Psych
    In the 1997 guidelines "orientation to time, place and person" is listed under the psychiatric system. Although I know every doctor I speak with says it is a measure of neurological function.

    1997 guidelines indicate that "mood and affect" are considered a bullet under psychiatric as well.

    F Tessa Bartels, CPC, CEMC

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