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.