This quick reference sheet illustrates the coding and documentation requirements for medication management services with, or without psychotherapy. This is a compliance issue that behavioral health practices must review. When reporting both an E/M service and psychotherapy by the same clinician on the same calendar day, a practitioner must use MDM to select the E/M service and may not double count any time.
- May be any type (category) of E/M service
- Usually an established patient visit (99212-99215) but can be used with other E/M codes
- Performed by a psychiatrist, psychiatric NP or PA
For additional details, see Medication Management and Psychotherapy.
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