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Alert & Oriented

  1. #1
    Default Alert & Oriented
    Medical Coding Books
    If a provider documents that a patient is "alert and oriented in no acute distress", does this count as a psych exam? I thought I had seen somewhere that it should be alert & oriented x3 but I can't find the source material.
    Thanks,
    Sue
    Sue Vermette, CPC, CPMA

  2. #2
    Location
    Milwaukee WI
    Posts
    4,466
    Default Constitutional
    Unless the physician specifies "alert & oriented x 3" I do not count this as psych, just part of describing the general appearance, which falls under constitutional.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Default
    Yes, it does help. Thanks!
    Sue Vermette, CPC, CPMA

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