Psychiatry Coding & Reimbursement Alert

Question: An established patient with a history of bipolar disorder and depression was seen in the outpatient clinic by our psychiatrist during an encounter that lasted 45 minutes. She came in because she needed medication refills and has had nausea, vomiting and a recent death in the family that has upset her.

The physician documented a past history review and conducted a full mental status exam and recommended that she continue on her current medications, which include psychotropics; she also recommended a treatment plan that encourages functional improvements, such as structured daily activities and decreased isolation and a return to the clinic in two months for reassessment.

California Subscriber

Answer: Because this encounter supports a medical evaluation and treatment regimen, you would use 90807 (Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services). Be sure that the note indicates that the physician spent 45 minutes in face-to-face time with the patient.