Medication management and Psychotherapy

Medication management performed by psychiatrists and medical psychiatric nurse practitioners and physician assistants is billed with Evaluation and Management codes. This could be any type of E/M service, a nursing facility service or home visit, but is most typically billed as an office/outpatient visit for an established patient, using codes 99212-99215.

Providing only medication management at the visit

The clinician selects a level of E/M service, 99212—99215 for medication management for established patients. The clinician may base the level of service on the key components of history, exam, and medical decision-making or on time, if counseling and coordination of care dominate the visit.

The psychiatry cheat sheet, shows the requirements for the key components of history, exam, and medical decision-making.  Two of the three components must meet or exceed the requirements. Or, if based on time, the typical time is listed on the sheet.

When using the key components, no specific documentation is required. When using time to select the level of service, the clinician should say something like, “I spent xx minutes face-to-face with the patient, over half in counseling.

Medication management and psychotherapy on the same calendar day

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