Wiki E/M with Psychotherapy Add On vs. Straight Psychotherapy

EJDD984

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I am looking for assistance understanding when a provider, psychiatrist in this case, should bill am E/M code and psychotherapy add-on and when it is more appropriate to bill just the psychotherapy code. I know the Dx can be the same for the E/M and add on, but they need to be distinct services.

If there are notes about medication administration or management, I can see how that would qualify an E/M charge but in the absence of that how can I tell if the Hist/Exam/MDM are not just being pulled from the psychotherapy session to justify and E/M charge?

We have a provider who bills in boilerplate fashion, all claims are billed with 99212 and 90836 and the same unspecified Dx, F41.9. Of note none of the medical records the provider has submitted are dated/signed, this is sufficient to deny the claims IMO but I want to also understand/address what I feel is incorrect coding.
 
I do know that when you are billing an add-on code with and E/M code, the notes must be completely separated. Example: The note for the E/M services is one note and the add-on note is completely seperate. Also, if the provider is NOT signing or dating the medical records, then I would think those records are not considered complete. We have not had good luck on billing add-on codes, especially since Medicare was paying very close attention to the records that were being submitted with these additional codes. If the psychiatrist is doing therapy, then you should bill for that therapy code. If he/she is perfoming Medication Management, then a E/M code should be used. If he/she is doing both, the main objective is to ensure the two notes are completely seperate. Hope this helps!
 
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