Documentation of Time when billing E&M with Psychotherapy

Angelaw1

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Hello all, my providers are in need of some clarification regarding whether to report total time or Just psychotherapy time on the chart notes when E&M is billed with Psychotherapy Add-on Codes. Do we need to put two separate time frames- the total time spent for the E&M services and then a separate time frame for the psychotherapy?
 

Angelaw1

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Thank you msbernards for your fast response. For further clarification: even though as of 2021, if billing psychotherapy with E&M, we have to base code selection on MDM not time, this does not mean the time spent providing E&M services does not need to be separately documented, correct? This is where we are getting confused.
 

llingblo

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From the Behavioral Health Certification course documents, the E/M with psychotherapy on the same day are defined as indicated below.

E/M with Psychotherapy on same day: When providing both an E/M service and psychotherapy on the same day, the E/M code is selected based on MDM rather than on-time. Time associated with activities to meet criteria of an E/M code cannot be included in psychotherapy time.

The documentation would still have to have shown all components of a E/M visit and then the start and stop time for the psychotherapy The add on code would be based on the time for the psychotherapy. The complete notes for the psychotherapy would have to be documented after the time.

MDM Moderate and 30 min psychotherapy
99214
+90833
 

sumithratc

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From the Behavioral Health Certification course documents, the E/M with psychotherapy on the same day are defined as indicated below.

E/M with Psychotherapy on same day: When providing both an E/M service and psychotherapy on the same day, the E/M code is selected based on MDM rather than on-time. Time associated with activities to meet criteria of an E/M code cannot be included in psychotherapy time.

The documentation would still have to have shown all components of a E/M visit and then the start and stop time for the psychotherapy The add on code would be based on the time for the psychotherapy. The complete notes for the psychotherapy would have to be documented after the time.

MDM Moderate and 30 min psychotherapy
99214
+90833
I agree. If its mentioned psychotherapeutic interventions in the document too.
 
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