Office Visit Code Selection for Medication Management

During certain appointments, psychiatrists, psychiatric nurse practitioners, or physician assistants may focus solely on medication management. At other times, they handle both prescription management and provide psychotherapy within the same visit. There are clear coding rules to follow when selecting the appropriate office visit code for encounters that include medication management alongside psychotherapy.

Selecting E/M Service Level When Only Medication Management Is Provided

If the visit involves only medication management, the practitioner can choose the level of Evaluation and Management (E/M) service based on either the complexity of the medication management or the total time spent during the visit. Since specific time ranges organize the codes, the practitioner should use the total time spent on that date of service to determine the appropriate code.

Coding Office Visits with Both Medication Management and Psychotherapy on the Same Day

When a practitioner provides both medication management and psychotherapy during the same visit, the level of service for office visit codes 99202 to 99215 or other E/M services must be determined based on the level of Medical Decision Making, rather than the duration of time. The time spent on medication management cannot be included in the psychotherapy time. Although medication management and psychotherapy are often combined during the visit, CPT coding requires separate documentation and reporting for each service.

While CPT does not require recording exact start and stop times, it is essential to check payer policies for any specific rules that may apply. The practitioner should select the office visit code based on Medical Decision Making and then select the psychotherapy code based solely on the time spent providing psychotherapy. Psychotherapy documentation must be detailed, patient-specific, and able to stand alone. Brief notes such as “xx minutes of supportive counseling” are not sufficient to support psychotherapy billing on the same day as medication management.

Documentation Requirements for Medication Management and Psychotherapy on the Same Day

When providing both medication management and psychotherapy during one visit, use a template that separates the documentation for each service.

Step One:

• Record a medically appropriate history of the present illness and review of systems related to the medication and condition.
• Complete a medically appropriate mental status examination.
• List all the patient’s conditions assessed and managed on this date, including the status of each condition.
• Determine the level of service based on the Medical Decision Making (MDM) framework.

Step Two:

• Label the next section as “Psychotherapy.” From a coding standpoint, add-on psychotherapy codes follow the same rules and requirements as stand-alone psychotherapy codes. They are based solely on the time spent, separate from medication management time.
• Clearly state the exact time spent providing psychotherapy; avoid using vague phrases like “16 minutes or more” or “38 minutes or more.” It is also uncommon that all therapy sessions exactly meet the minimum time thresholds.
• Include a detailed, patient-centered description of the psychotherapy session, such as:
  • Type of psychotherapy used (for example, CBT, insight-oriented, DBT)
  • Patient observations, including mental status exam findings
  • Description of patient symptoms and whether they have improved or worsened
  • Patient’s account of events or situations and discussion with the therapist about the patient’s response
  • Interaction between therapist and patient, including responses to therapy
  • Any homework assignments from previous sessions
  • Therapist’s interventions, questions, suggestions, interpretations, reframing, and collaborative planning
  • Therapy goals and any periodic summaries of progress or treatment plan updates
  • Avoid generic or repetitive goal statements that are not specific to the patient.
  • Diagnoses and condition status
  • Signature and credentials of the practitioner
• Select the psychotherapy code based only on the time spent in psychotherapy and document this time.

Essential Documentation for Medication Management and Psychotherapy

• When both medication management and psychotherapy are provided during a visit, practitioners must document the time spent on psychotherapy and include a detailed description of the therapy. Office visit levels should be determined based on medical decision-making rather than time when billing, as per the Centers for Medicare & Medicaid Services (CMS).

• Suppose medication management is the only service performed on the date of service. In that case, the clinician may choose the E/M code based on either time or medical decision making for office visit codes 99202 through 99215.

Initial Evaluation and Follow-up Visit Coding

Psychiatric physicians, nurse practitioners, and physician assistants manage the medication for patients with complex behavioral conditions. The initial evaluation is typically billed with code 90792, which is a psychiatric diagnostic evaluation with medical services. Still, it can also be reported with new patient visit codes if the patient meets the criteria for a new patient. The follow-up visits are billed using established patient visit codes, 99212 - 99215.

Selecting Level of Service for Medication Management Only

If medication management is the only service performed on that day, the practitioner can use the time for medical decision-making. For medication management purposes only, the practitioner may use total time (including face-to-face and non-face-to-face time) or medical decision-making (MDM) to determine the level of established patient visit.

Documentation for Psychotherapy Visits

The note must have patient-centered details and describe the nature, type, and content of the therapy visit. It might explain a situation that has occurred since the patient was last seen, and the practitioner would explore the patient’s response to the problem. The therapy note may refer back to interventions recommended at a prior visit or suggest work that the patient can complete before the next visit. The interaction in the session is described.

Simplify Your Psychiatric Billing with BillingFreedom

BillingFreedom streamlines the complex billing process for psychiatric medication management and psychotherapy services. Our expert team ensures accurate coding for initial evaluations and follow-up visits, including the proper use of codes such as 90792 and 99212–99215. Whether your practice bills based on time or medical decision making, we handle all the details to maximize your reimbursements while maintaining full compliance with payer policies.

With BillingFreedom, detailed documentation requirements are seamlessly managed. We help you maintain patient-centered notes that clearly describe therapy sessions, track goals, and document progress, so you meet all payer requirements effortlessly. Focus on providing exceptional patient care while we handle the billing complexities. Choose BillingFreedom for reliable, efficient, and compliant behavioral health billing services tailored to your practice needs.

For more details about our exceptional mental health billing services, please don't hesitate to contact us via email at info@billingfreedom.com or call us at +1 (855) 415-3472. 

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