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Psychiatry Coding & Reimbursement Alert

Reader Question:

Can You Report E/M With No Changes to Medications? Find Out

Question: If our psychiatrist is performing pharmacological management but is not prescribing any new meds or making any changes to the old medication, can an E/M code still be reported for the encounter?

Iowa Subscriber

Answer: When your clinician performs medication management, he will review past medication history and will assess the patient for any adverse effects of the medications he has been taking. Based on this, he may or may not make any adjustments to the drug dosage or decide to add new medications to the list.

Even though he does not make any changes to old medications or prescribe any new medications in these encounters, you are still allowed to report E/M codes (such as 99212, Office or other outpatient visit for the evaluation and management of an established patient) for the encounter as he would have recorded medication history and formulated the treatment plan (i.e., performed medical decision-making) based on studying the effects and adverse effects of the medications that the patient is taking.