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coding and documentation using the recently revised outpatient E/M code requirements. The following guidance will help you select the appropriate level of an outpatient E/M service and document it correctly. The guidance includes documentation examples and the definition of time.
This template includes the essential documentation required to be included when psychotherapy is provided together an E/M service (99212 or 99213 plus either a 90833 (30 minutes) or 90836 (45 minutes).
It contains guided steps for how to bill patients for psychiatric services at Rula, outlines example scenarios, details information on medical decision-making (MDM), and has a list of current CPT codes for psych outpatient services.
Codes 90833, 90835, and 90838 MUST be submitted with E/M services by either the MD/DO or NPP Code 90846 is used for family psychotherapy without patient present
Standalone psychotherapy codes (90832, 90834, 90837) should not be used in conjunction with an E/M service. Per CPT guidelines, “To report both E/M and psychotherapy, the two services must be significant and separately identifiable.”
Procedure codes 90833, 90836 and 90838 are add on codes that should be used in conjunction with evaluation and management (E/M) codes 99201-99239, 99304-99337, 99341-99350. Psychotherapy codes that include an evaluation and management component are payable only to physicians, PAs, NPs and CNSs.
+90833 - Use add-on code for Individual psychotherapy, insight oriented, behavior modifying and/or supportive, 30 minutes with the patient and/or family member (time range 16-37 minutes), when performed with an evaluation and management service.
