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.
Psychiatrists and nurse practitioners use E/M codes to code medical services provided outside of psychotherapy, like medication management. Ahead, find out how to use them for evaluation and management services.
Evaluation and management (E/M) codes are a subset of CPT codes established by the American Medical Association (AMA) to represent services provided by physicians to assess and manage a patient’s health. E/M codes range from 99201 to 99499, and include care such as hospital observation services, emergency department services, and newborn care services, among others.
Unlike other CPT codes that designate time spent providing a service, specific procedures, or interventions, E/M codes reflect the physician’s effort to deploy various tasks — like history-taking, examination, communication, and medical decision making — in a patient encounter in order to determine appropriate care.
Using E/M codes for behavioral healthcare
Behavioral health prescribers — such as psychiatrists and nurse practitioners — are most likely to use E/M codes ranging from 99201–99215, which represent “Office/other outpatient services” in the CPT codebook.
As a psychiatrist or nurse practitioner, you might decide to use an E/M code instead of a code for psychotherapy (like 90837 or 90834) when you’re providing a service that is more medically oriented, or when the coordination or assessment of care is the primary focus.
E/M coding cheat sheet for behavioral health
If you’re looking for an E/M code to bill your services as a psychiatrist or nurse practitioner, the appropriate code depends on, first:
New vs. established patient: There are separate codes for these two patient populations, based on whether the patient has received a service from the same physician or physician group practice under the same specialty within the previous 3 years. As a Headway provider, if you’re seeing a patient who is new to you but has seen a different Headway provider within the past three years, you would bill an established patient code rather than an intake code.
Medical decision making (MDM): Though a patient may be subjectively complex or challenging, for billing purposes complexity is based on meeting or exceeding two of the three elements required for the level of medical decision making represented by the established MDM level of the code: straightforward, low, moderate, or high. (See the MDM table here.)
E/M codes for office/other outpatient services:
The following codes apply to E/M services provided by a qualified medical professional:
Psychotherapy add-on codes, for use with E/M codes:
If you’re both evaluating a patient’s health and providing talk therapy in the same encounter, you can use an E/M code along with a psychotherapy add-on code.
To ensure accurate documentation, it's essential to separately record the details of each service. For the E/M portion, focus on the medical evaluation and decision-making, and for the psychotherapy session, document the therapeutic techniques and interventions used. Both sections should stand alone in the session notes, reflecting that they are distinct components of the overall encounter.
Psychotherapy add-on codes:
90833: Individual psychotherapy, 30 minutes (16-37 minutes face to face with the patient)
90836: Individual psychotherapy, 45 minutes (38-52 minutes face to face with the patient)
90838: Individual psychotherapy, 60 minutes (53 minutes or more face to face with the patient)
When incorporating psychotherapy add-on codes, your full documentation must include:
Total time spent in the session. (This will include evaluation and management time plus psychotherapy time.)
Time specifically spent conducting psychotherapy. (Expressed as an exact length of time, not a range.)
Modality/intervention type of psychotherapy delivered, and reasoning/plan for the psychotherapy time.
How do I know which method (MDM or total time) to use to select the level of visit?
If you’re coding an E/M code alone, you should select an E/M code using whichever method — time or MDM — best captures the nature of your service during the encounter.
If you’re coding an E/M code along with a psychotherapy add-on code, your use of an E/M code must be based on MDM.
It’s important to include sufficient documentation to support the method you chose. For example: To code a brief encounter with a high-complexity patient, MDM might be a better reflection of the role you played as a medical provider. On the other hand, if you spent a length of time consulting a patient with a straightforward situation, it might be better to code based on total time.
Documentation of work on the date of service is imperative when billing based on time. Be sure to justify why you spent a certain amount of time with the client within your documentation.
The following activities count toward time when coding an E/M service:
Preparing to see the patient on the date of service (e.g., review of tests)
Obtaining and/or reviewing the separately obtained history on the date of service
Performing a medically appropriate examination and/or evaluation on the date of service
Ordering medications, tests, and procedures on the date of service
Counseling and educating the patient/family/caregiver on the date of service
Referring and communicating with other health care professionals (when not reported separately) on the date of service
Documenting clinical information in the electronic or other health records
Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
Care coordination (not separately reported)
The following activities do not count toward time when coding an E/M service:
Time spent on a previous or subsequent day
Activities performed by clinical staff (i.e., RNs, MAs)
When the E/M is warranted and separately identifiable, the time spent on separately reportable services (such as procedures, diagnostic tests, and professional interpretation) cannot be combined with the E/M time
Time spent on travel
Time spent on teaching that is general
How to select E/M codes by level of medical decision making
Medical decision making, or MDM, is a structured assessment that helps to reflect the complexity of work required by the provider in order to diagnose and treat the patient’s condition.
There are three elements of MDM, which can be graded on four distinct levels.
3 MDM elements
MDM is based on three elements, as defined by the AMA:
Number and complexity of problems addressed at the encounter
Amount and/or complexity of data to be reviewed and analyzed (Note: As an additional layer to this assessment, this element contains another embedded evaluation of “category,” which specifies the proper combination of tests, orders, or documents that contribute to meeting the criteria for that level.)
Risk of complications and/or morbidity or mortality of patient management
4 MDM levels
E/M codes are graded on four levels of MDM, each with their own criteria for the three elements above:
Straightforward
Low
Moderate
High
In order to meet the criteria for a specific level of MDM, the criteria for two out of three of the elements must be met. For example, a patient who meets the criteria for a straightforward number and complexity of problems and carries a low level of risk of complications, the MDM would be considered straightforward.
To better understand the terms in this chart, and how they apply to mental health care, consult the glossary below.
Commonly used E/M coding terms
These key terms are likely to come up when you’re assessing E/M codes.
Definition of new patient vs. established or existing patient
New patient:
An individual who has not received any professional services, Evaluation and Management (E/M) service or other face-to-face service (e.g., surgical procedure) from the same physician or physician group practice and the same specialty within the previous 3 years.
Established patient / Existing patient:
An individual who has received professional services from the physician or another physician in the same group and the same specialty within the previous 3 years.
Definitions for terms related to: Complexity of problems
Self-limited minor problem:
A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.
Example: Bereavement
Stable, chronic illness:
A problem with an expected duration of at least one year or until the death of the patient. Conditions are treated as chronic whether or not stage or severity changes.
Example: Uncontrolled diabetes and controlled diabetes are a single chronic condition.
"Stable,” for the purposes of categorizing MDM, is defined by the specific treatment goals for an individual patient. A patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function.
Example: Major Depressive Disorder, recurrent, in remission
Stable, acute illness:
A problem that is new or recent for which treatment has been initiated. The patient is improved and, while resolution may not be complete, is stable with respect to this condition.
Example: Acute stress reaction
Acute, uncomplicated illness:
A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. A problem that is normally self limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness.
Example: Adjustment disorder with depressed mood
Acute, complicated illness:
An illness that causes systemic symptoms and has a high risk of morbidity without treatment.
Example: Anorexia with bradycardia or amenorrhea
Chronic illnesses with exacerbation, progression or side effects from treatment:
A chronic illness that is acutely worsening, poorly controlled, or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects.
Example: Major Depressive Disorder, recurrent; moderate
Undiagnosed new problem with uncertain prognosis:
A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment.
Example: Cognitive decline
Chronic illness with severe exacerbation, progression, or side-effects of treatment:
The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require escalation in level of care.
Example: Major Depressive Disorder, recurrent, severe w/ significant functional decline
Acute or chronic illness or injury that poses a threat to life or bodily function:
An acute illness with systemic symptoms, an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without treatment. Some symptoms may represent a condition that is significantly probable and poses a potential threat to life or bodily function. These may be included in this category when the evaluation and treatment are consistent with this degree of potential severity.
Example: Depression with suicidal ideation and plan
Definitions for terms related to: Risk of complications, morbidity, or mortality of patient management
Social determinants of health:
Economic and social conditions that influence the health of people and communities. Examples of social determinants of health that contribute to medication non-adherence include food or housing insecurity.
Drug therapy requiring intensive monitoring for toxicity:
A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. The monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy. (Intensive monitoring is defined as obtaining lab results at an interval of not more than every 90 days.)
Examples: Initiation of Lithium, management of Clozapine
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.
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How to use CPT code 99203
How to use CPT code 99204