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Considerations for billing E/M codes in the outpatient setting
Providers use CPT (Current Procedural Terminology) codes when confirming sessions in our system. These codes correspond with things like the type of care provided (i.e., psychotherapy) and the length of time for the session. Read more about CPT codes on Headway.
E/M (Evaluation and Management) codes are a specific range of CPT codes used primarily by a certain kind of provider—typically physicians, psychiatrists and nurse practitioners—who evaluate and manage a client’s health.
A few common examples of E/M codes include:
Codes for an office or other outpatient visit for new clients with the following session lengths
- 99202 (Straightforward): 15-29 minutes
- 99203 (Low MDM): 30-44 minutes
- 99204 (Moderate MDM): 45-59 minutes
- 99205 (High MDM): 60-74 minutes
Codes for an office or other outpatient visit for established clients with the following session lengths:
- 99212 (Straightforward): 10-19 minutes
- 99213 (Low MDM): 20-29 minutes
- 99214 (Moderate MDM): 30-39 minutes
- 99215 (High MDM): 40-54 minutes
There are two approaches to keep in mind when billing Evaluation and Management (E/M) Services in the outpatient setting:
- If coding for an E/M code alone, such as those listed above, you may select your code based on the length of the session or Medical Decision Making.
- If coding an E/M code along with psychotherapy, you must use Medical Decision Making (MDM) to justify your use of the E/M code.
Medical Decision Making (MDM)
MDM is a type of decision making that helps establish diagnosis, assess the status of a condition, and determine the right kind of management. It’s typically broken into three elements:
- The number and complexity of problem(s) that are addressed during the session.
- The amount or complexity of data you need to review and analyze. This data includes medical records, tests, and/or other information that must be obtained, ordered and reviewed. This also might include information obtained from multiple sources or other team members.
- The risk of complications, morbidity or mortality arising from management decisions made at the visit—associated with the client’s problem(s), the diagnostic procedure(s), and treatment(s).
Note that comorbidities are not considered unless they are addressed during the session or add complexity or risk to the management of the client.
Please visit this AMA guide for the latest criteria for MDM, starting with the chart on page 8: Evaluation and Management Service Guidelines.
E/M services can sometimes require add-on codes if you provide further care or psychotherapy in addition to medical and evaluation. For example, the following codes can be added:
- 90833: Individual psychotherapy, 30 minutes
- 16-37 minutes face to face with the client
- 90836: Individual psychotherapy, 45 minutes
- 38-52 minutes face to face with the client
- 90838 - Individual psychotherapy, 60 minutes
- 53 minutes or more face to face with the client
For psychotherapy add-on codes, documentation must include:
- Total time spent in the session
- Time specifically spent conducting psychotherapy
- Modality/intervention type of psychotherapy delivered and reasoning/plan for the psychotherapy time
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.