Essential documentation for medication management and psychotherapy

• When providing both medication management and psychotherapy, practitioners need to document the time spent in psychotherapy and describe the therapy. Beginning January of 2021, when billing an office visit, select the level of visit based on medical decision making, not time.
• If medication management is the only service performed on that date, the clinician can select the E/M code based on time, or medical decision making for office visit codes 99202–99215.

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, psychiatric diagnostic evaluation with medical services, but 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 with established patient visit codes, 99212—99215. Login to read the rest of this article

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