Psychiatry Coding & Reimbursement Alert
Count Time When Clinician Discusses Treatment Options
Question: My psychiatrist did a counseling session with the parents of a minor regarding the minor’s proposed treatments. Our clinician diagnosed the boy with attention deficit hyperactivity disorder (ADHD). He spent a good 20 to 30 minutes with the parents answering questions. Is there a code I can use for this?
California Subscriber
Answer: You should bill this as an E/M encounter based on time. If the counseling and/or coordination of care dominates — makes up more than 50 percent of the physician/patient and/or family encounter (face-to-face in office or other outpatient settings), time alone can be the key or controlling factor to qualify for a particular level of E/M service, such as 99201-99215.
Base your choice of an E/M service on the specific time your psychiatrist documented in the patient’s chart. If the encounter lasted between 20 and 30 minutes, 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity ... Typically,25 minutes are spent face-to-face with the patient and/or family) is likely your best code choice for an established patient visit.
Psychiatry Coding & Reimbursement Alert
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