CodingIntel

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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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Last revised December 17, 2020 - Betsy Nicoletti
Tags: behavioral health

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Our mission is to provide accurate, comprehensive, up-to-date coding information, allowing medical practices to increase revenue, decrease coding denials and reduce compliance risk. That's what coding knowledge can do.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions. For more about Betsy visit www.betsynicoletti.com.

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