Review each code against the documented service and current payer rules. Coding tools can flag possible mismatches for clinician review.
Match the code to documented work
Select codes 99213 through 99215 by documented medical decision-making or total time when billed without a psychotherapy add-on. When you bill 90833, 90836, or 90838, select the E/M level by medical decision-making. Do not include psychotherapy time in the E/M selection.
Match the billed level to the documentation
The record must support the selected E/M level. Review each suggestion before you apply it.
Psychotherapy add-on codes
Codes 90833, 90836, and 90838 apply to psychotherapy provided with an E/M service. The psychotherapy must be significant and separately identifiable.
Document the psychotherapy time. Code 90833 covers 16-37 minutes, 90836 covers 38-52 minutes, and 90838 covers 53 minutes or more.
Review CMS office and outpatient E/M guidance, CMS psychotherapy guidance, and current payer rules before billing.
E&M code selection: 99213 vs 99214 vs 99215
For codes 99213 through 99215, review the documented medical decision-making or total time. If you bill a psychotherapy add-on, use medical decision-making to select the E/M level.
Psychotherapy code review
Code 90834 covers 38-52 minutes. Code 90837 covers 53 minutes or more. Document the session time and the psychotherapy service.
Review intervention language, treatment plan progress, risk assessments, and time before you select a code.
Documentation requirements
The note has to support every code billed.
For an E/M level, document the medical decision-making or total time used to select the code. If you bill a psychotherapy add-on, document the separate service, intervention, response, and psychotherapy time.
Update the treatment plan when it changes. Complete a risk assessment when clinically indicated. Give a rationale for each medication change.
Review each visit for coding accuracy
Compare each billed code with the documentation. Review each mismatch. Apply a code only when the documentation and payer rules support it.