Billing the E/M on MDM When Using Add on Psychotherapy

ADD ON THERAPY -- E/M Must be Coded by Time

Add-on psychotherapy refers to additional psychotherapeutic services provided alongside other medical services, e.g., E/M services in psychiatry. These services are often necessary to address a patient's mental health needs in conjunction with their primary medical concerns. Incorporating psychotherapy into the overall treatment plan enhances the holistic approach to patient care.

When it comes to coding for add-on psychotherapy, using an E/M code based on time is crucial.

1. Two time based codes cannot be used in the same visit

2. Add on psychotherapy cannot be billed based on medical complexity and is ONLY based on time

3. Thus, the E/M code for that part of your visit must be based on MDM elements and complexity.

Make sure you documentation for this is clear and makes it evident that the E/M portion was billed on complexity and the add on code was based on time. You can write this in your note: "99213 billed based on MDM." (followed by your documentation of that service.)

Write the total number of minutes you spent providing the identifiable add on psychotherapy service; those minutes do not need to be all at one time. It IS okay if the add on psychotherapy was provided in a few different chunks during the visit and the TOTAL time is what determines the exact code.

"+90833. 17 minutes of CBT provided." (followed by your documentation of that service)