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Wiki What/how much EM to bill 90805 vs 90804?

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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?
 
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.
 
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