In the field of psychiatry, practitioners share a common headache with the rest of the medical industry – medical coding and billing. It is essential that psychiatrists understand the nuances of this complex area in order to maximize reimbursement and avoid payer audits. A particularly important facet of psychiatric billing is using the correct codes for evaluation and management (E/M) services. In fact, knowledge of the E/M coding basics is key to financial survival in the modern psychiatric world.
So what are the E/M codes for psychiatrists? When are E/M codes necessary? How does a psychiatrist select the correct codes? What supporting documentation does a psychiatrist need for her E/M coding? We explore these issues and more below.
When Are E/M Codes Necessary for Psychiatric Treatment?
E/M codes are a subset of the Current Procedural Terminology (CPT) codes – the uniform coding system developed by the American Medical Association (AMA) and adopted by the Centers for Medicare and Medicaid Services (CMS) and other healthcare payers. The CPT codes for E/M services all contain five digits and begin with the digits “99”, with a range of 99202-99499. When billing for psychiatric evaluation and management services, either alone or with psychotherapy, E/M codes are the appropriate choice.
The Basics of Selecting the Correct Psychiatric E/M Codes
E/M code selection is generally based on the following factors: (1) whether the patient is new or established, (2) the treatment setting (outpatient, inpatient, nursing facility, etc.), and (3) the level of complexity of the service provided. For example, CPT 99202-99205 are for outpatient E/M services for a new patient, while codes 99221-99223 are intended for inpatient hospital E/M services for either new or established patients.
With the CPT revisions that went into effect on January 1, 2021, coding has changed substantially for office and outpatient E/M services. To understand the changes, we can first examine E/M coding for non-outpatient E/M services.
Non-Outpatient E/M Coding – 3 Components of Care
There are three necessary components of care to justify non-outpatient E/M coding, detailed below: (1) history, (2) examination, and (3) medical decision-making (MDM).
- History: The history section must include the patient’s chief complaint, the history of their present illness, family and/or social history, and a review of body systems. The four history types, in ascending order of billing amount, are (1) problem-focused, (2) expanded problem-focused, (3) detailed, and (4) comprehensive.
- Examination: This section details the type of examination performed based on the nature of the problem and the psychiatrist’s best judgment. The levels of examination type are the same as for history types, ranging from problem-focused to comprehensive.
- Medical Decision-Making (MDM): The level of MDM is based on several factors, including (1) the number of diagnosis or management options, (2) the amount and/or complexity of data to be reviewed, and (3) the risk of complications. The complexity levels of MDM are straightforward, low, moderate, and high.
This framework applies to all E/M services other than office or outpatient services, such as hospital observation, inpatient, nursing facility, etc.
Office/Outpatient E/M Coding – Time & Complexity are Main Factors
According to the AMA, the administrative burden of reporting requirements for office visits and other E/M codes has weighed down the physician community for decades. To address the problem, the AMA approved revisions in 2019 to simplify and streamline the reporting process for this type of care, which took effect at the beginning of 2021.
The 2021 CPT revisions specifically addressed the required components for E/M services provided during office or outpatient visits (CPT 99201-99215). One basic change was the elimination of CPT 99201, formerly used for outpatient E/M services for a new patient with a presenting problem of “self-limited or minor” severity. Now there are only 4 levels of complexity for outpatient E/M services for new patients, reflected in CPT 99202-99205.
In addition, the required components of care were simplified for office and outpatient E/M coding. A history and examination are no longer required. Instead, the psychiatrist can select the E/M code based on either the level of MDM or the time spent, at the discretion of the practitioner.
Essentially, time and complexity are now the two main options for outpatient E/M code selection, and the physician can select the one that is more financially advantageous. For example, CPT 99213 is the appropriate code for outpatient E/M care for an established patient for either (1) a low level of MDM or (2) 20-29 minutes total time spent on the date of the encounter.
The 2021 revisions also changed the calculation for “time spent” to include activities beyond face time with the patient. These activities include care coordination, documenting clinical information in the EHR, counseling the patient’s family or caregiver, and other common time-consuming tasks for busy psychiatrists.
Using Add-on E/M Codes for Psychiatrists
Psychiatrists billing for E/M care also need to know their add-on codes. An add-on code, designated with a “+” in the CPT manual, can only be used in conjunction with a primary code. For example, psychotherapy add-on codes are commonly used when psychotherapy services are rendered during an E/M encounter.
Another key addition with the 2021 CPT revisions was a new add-on code for prolonged office or outpatient E/M services. Specifically, CPT 99417 can be billed once for every 15-minute increment beyond the maximum time threshold for the primary codes. For time-based billing for outpatient E/M services for a new patient, the highest-paying primary code a psychiatrist could bill would be CPT 99205, for 60 minutes. However, the practitioner can now use add-on code 99417 for each 15-minute increment beyond the initial hour.
Valant Can Handle Your Practice’s E/M Coding
As behavioral health practices continue their ongoing shift toward electronic health records (EHR), they should seek out EHR software that can assist with E/M coding. Ideally, a practice’s EHR should be able to incorporate the 2021 CPT revisions and have the capacity to handle either time-based or complexity-based billing for outpatient E/M services.
Valant’s EHR has long had the capability to provide support for coding based on the MDM level of complexity. Now Valant has added tabs allowing users to precisely document both complexity and time spent, which are accessible through the Managed Mobile Notes Templates feature.
Explore whether Valant is a good fit for your practice in its quest to streamline E/M coding and maximize reimbursement. Request a demo today.