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Psychiatry Coding & Reimbursement Alert

You Be the Coder:

Confused Over Reporting E/M For No Meds Management? Here's What to do

Question: One of our psychiatrists saw a patient for a scheduled psychotherapy session. Prior to the session, the patient complained that his depression symptoms had increased. The patient was not on any prior medications. Owing to the change in symptoms, our clinician reevaluated the patient for prescribing medications, but in the end, he did not prescribe any new medications. He then continued on with the scheduled psychotherapy session for duration of 30 minutes. Can I report an E/M code even though no medicines were prescribed for the patient? Also, should I report the psychotherapy session with 90832 or the corresponding add-on code?

Michigan Subscriber

Answer: Even though your clinician did not prescribe any medications to the patient, he still evaluated the patient for the change in symptoms and to see if prescribing medications will help in alleviating them. So, your clinician did perform an evaluation and management of the patient even though no medications were introduced. Prescribing medications is not a prerequisite or requirement to report an E/M code and the decision not to prescribe medications can be just as representative of medical decision making as the decision to prescribe.

So, depending on the components of the evaluation and the management of the patient during the encounter, an appropriate established patient E/M code (such as 99212, Office or other outpatient visit for the evaluation and management of an established patient…) can be reported.

Since you are reporting an E/M code for the visit, the subsequent psychotherapy that your clinician performed should be reported with an appropriate add-on psychotherapy code. Since the psychotherapy lasted for 30 minutes duration, you can report +90833 (Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service [List separately in addition to the code for primary procedure]) for the psychotherapy session in addition to the E/M code that you are reporting.