What/how much EM to bill 90805 vs 90804?

[1073358]

What do you look for in a note to determine if you should bill therapy with or without EM component? I am curious what others do to determine. I would like examples. If dr mentions meds or changes them, is that enough to consider it with EM? What else do you watch for if anything?

[deyoung]

Hi, I am looking at the BH coding and pymt guide from ingenix and it says you also need to document one or more of the following for E/M component:

• discussion of any clinical or medical d/o that may be influencing or affecting the patient's psych status
• any institution or continuation of psych or nonpsych medications
• any other service requiring an MD or DO licensure

hope this helps.

[1073358]

Great-all the ones that I code EM for are having medicine conversations and adjustments so that means I am on track!