How to use CPT code 99213
Code 99213 represents an existing patient appointment that’s at least 20 minutes in duration.
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How to use CPT code 99214
How to use E/M codes for evaluation and management services
Billing and coding
How to use CPT code 90838
Code 90838 represents an add-on for at least 53 minutes of psychotherapy with an E/M code.
The 90838 code is an add-on therapy code used by prescribing providers. For other E/M codes, visit this overview.
CPT code 90838 description
Code 90838 represents an add-on for 53 or more minutes of psychotherapy to a new patient or existing patient E/M code. This code can’t be billed by itself or with a non-E/M code. When you add to an E/M code, the E/M code has to be billed based on medical decision-making, not time.
90838 is a prescriber code, so it’s most commonly used by psychiatrists and nurse practitioners.
This is is how the American Medical Association defines 90838 in the official CPT codebook:
CPT code 90838:
60 minutes with patient when performed with an evaluation and management service
CPT code 90838 time frame
It’s important to use the code that most accurately reflects the time you spent with the patient to treat their condition, and ensure that documentation for the session supports the chosen code.
CPT code 90838 documentation
Code 90838 documentation has specific guidelines as a therapy add-on code. It should be in the same note as the E/M code, but in a separate section.
The example note below includes documentation for a 90838 session, because the client displays moderate risk with two stable illnesses requiring moderate levels of MDM associated with illness monitoring, ongoing support, and prescription treatment.
The 60 minutes spent on psychotherapy during the encounter falls within the 53 or more minutes range required for reporting add-on CPT code 90838.
Patient Name: Sallie Mae
Date of Service: 04/16/2023
Patient DOB: 06/29/1945
Appointment Time: 11:00am-12:15pm
Place of Service: Patient was located at their home at 123 Main St Anywhere US 12345
Provider was located at their office: 456 Storybook Ln Hollywood CA 96852
This session was provided via a HIPAA compliant interactive audio/video platform. The patient consented to this telemedicine encounter.
The total time I spent caring for this patient today was 75 minutes which included: interviewing the client, documenting, reviewing the patient's responses to questionnaires, discussing treatment plans, coordinating care, prescription management and counseling the client on managing her mental health.
Subjective
Chief Complaint: Follow-up consultation for a 77-year-old female, presenting with exacerbation of symptoms related to her chronic mental health conditions.
History of Present Illness: Sallie reports a recent escalation in symptoms associated with both depression and post-traumatic stress disorder (PTSD). She describes increased feelings of sadness, hopelessness, and intrusive thoughts related to traumatic experiences. Sleep disturbances, including nightmares and insomnia, have intensified, impacting his overall functioning and ability to maintain daily routines. Sallie acknowledges heightened irritability and difficulty concentrating at work, further exacerbating her distress
Psychosocial History: Married, 2 children at home, works in office, college graduate, parent good relationship
Behavioral Health/Psychiatric History: therapy previously, no hospitalizations
Medical History: High BP, knee surgery
Current Medications: prazosin 1 mg at bedtime, sertraline 100 mg 1xday
Allergies: NKA
Objective
Exam: Vital signs stable. Patient displays signs of psychomotor agitation and hyperarousal. Mood observed as consistently low, with increased anxiety evident during the examination.
ROS:
Constitutional: denies unexplained weight loss or weight gain, fever, night sweats HEENT: denies
Cardiovascular: denies
Respiratory: denies
Neurological: denies
Psychiatric: depression
Gastro: denies
Musculoskeletal: denies
Tests: The patient's score on PHQ-9 was 9 suggestive of mild depression. The patient's score on GAD-7 was 7 suggestive of mild anxiety.
MSE: Orientation: Alert & Orientedx3
Appearance: neatly dressed, appears stated age
Speech: Normal
Perception: Normal
Thought content: logical
Insight/judgment: Normal
Cognition: Normal
Substance Abuse Assessment: 2-3 drinks alcohol/month, nonsmoker, no recreational drug use
Risk Assessment: No SI/HI, overall risk is moderate. Safety plan has been established.
Assessment
F33.2 Major depressive disorder, recurrent, with exacerbation:
Sallie presents with recurrent episodes of major depressive disorder, currently experiencing an exacerbation. Her symptoms meet the DSM-5 criteria for Major Depressive Disorder, as follows:
- Depressed Mood: Increased feelings of sadness and hopelessness.
- Anhedonia: Diminished interest or pleasure in activities.
- Sleep Disturbances: Insomnia.
- Psychomotor Changes: No specific details provided.
- Fatigue or Loss of Energy: Impact on overall functioning and daily routines.
- Feelings of Worthlessness or Excessive Guilt: Not explicitly stated, but feelings of hopelessness imply negative self-perception.
- Diminished Ability to Think or Concentrate: Difficulty concentrating at work. F43.12 Post-traumatic stress disorder, chronic, exacerbated by recent stressors:
Sallie has a chronic history of post-traumatic stress disorder, now exacerbated by recent stressors. Her symptoms meet the DSM-5 criteria for PTSD, as follows:
- Intrusion Symptoms: Intrusive thoughts related to traumatic experiences and nightmares.
- Avoidance: Not explicitly mentioned, but can be inferred from difficulty concentrating and heightened distress.
- Negative Alterations in Cognition and Mood: Increased feelings of sadness, hopelessness, and irritability.
- Alterations in Arousal and Reactivity: Heightened irritability, difficulty concentrating, and insomnia.
Plan
1. Adjustment Of Medication Regimen:
- Increase dosage of sertraline from 100 mg to 150 mg daily for enhanced management of depressive symptoms.
- Initiate low-dose prazosin (1 mg at bedtime) to target PTSD-related nightmares and improve sleep quality.
2. Referral for intensive psychotherapy:
Implement weekly sessions of prolonged exposure therapy (PET) to address PTSD symptoms and facilitate emotional processing of traumatic experiences.
3. Safety monitoring: Personalized safety plan was developed to address potential suicidal ideation or self-harm behaviors.
4. Follow-up and next steps:
- Schedule bi-weekly follow-up appointments to monitor response to treatment, adjust medication as necessary, and evaluate progress in psychotherapy.
- Collaborate with patient to establish a social goal: Sallie will endeavor to engage in at least one social activity per week to foster social support and reduce feelings of isolation.
- Sallie has been advised to adhere to her medication regimen and of the risks/side effects of the medications. Sallie will call the office during office hours to report side effects. In case of emergency, please go to your nearest Emergency Room or call 911/988.
Psychotherapy: 11:15am - 12:15pm
Behavior(s) addressed: sadness, hopelessness, and intrusive thoughts related to traumatic experiences
Interventions used: supportive therapy and utilized CBT techniques to reframe cognitive distortions
Response: Fair, minor reduction in sadness and intrusive thoughts
Goal/Plan: Sallie will decrease frequency and intensity of intrusive thoughts and episodes of sadness by utilizing coping strategies, referral to PET therapist for more in-depth work on trauma-related issues
Electronically signed by,
[Provider name, Credentials, Date signed]
__________________________________________________________________________________________
Rationale information is not required in your note; it is provided for educational purposes only.
Rationale and How the CPT Codes Were Selected:
Number and Complexity of Problems Addressed: 2 Chronic illnesses with exacerbation
Data Reviewed/Analyzed: PHQ-9, GAD-7
Risk: Moderate: Prescription drug management
Rationale: The client displays High number & complexity of problems with two chronic illnesses with exacerbation, Low amount of data reviewed, and Moderate risk for prescription management. A total of 42 minutes of psychotherapy was provided during the session.
Level of MDM: Moderate CPT Code Selected: 99214 + 90838
CPT code 90838 reimbursement rates
Reimbursement rates for sessions billed with 90838 will vary based on the specific payer contract, your geographic location, and type of therapy license. Headway providers can check the portal for rates with each insurance provider.
This document is intended for educational purposes only. It is designed to facilitate compliance with payer requirements and applicable law, but please note that the applicable laws and requirements vary from payer to payer and state to state. Please check with your legal counsel or state licensing board for specific requirements.
Billing and coding
How to use CPT code 99213
How to use CPT code 99214
Code 99214 represents an existing patient appointment that’s at least 30 minutes in duration.
How to use E/M codes for evaluation and management services
Within behavioral health, billing and documentation for E/M codes can sometimes be confusing.