CPT Coding Changes

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Subject: Combining E&M and Psychotherapy Codes on a single encounter

1.  Combining E&M and Psychotherapy Codes on a single encounter

Posted 10-28-2013 06:19 PM
In my clinic we code for psychotherapy and for E&M.

I do not use time for the E&M code, but rather it is based on the required number of elements for a given E&M code.  For example:

I see a patient for a follow-up visit.  The patient has both Bipolar Disorder Type I MRE Depressed, Hypertension, and Fibromyalgia.   I include short supportive psychotherapy for about 16 minutes and use code 90832 (16 - 30 minutes pf psychotherapy) plus a review of vital signs, review of systems (at least 3 systems) and note the patient's progress with medication and focused areas related to her illnesses.  I add the 99213 E&M code (moderate complexity). To deal with the time factor (for psychotherapy) I note the start time and the end time of the encounter in the progress note.  For this encounter the start time is 2:59 PM and the stop time is 3:30.  Then at the end of the progress note I document "I spent 16 minutes of 31 minutes providing supportive psychotherapy focused on ________.  This way for auditors, it is clear that 16 minutes (the minimum for 90832) of the encounter was devoted to psychotherapy.  The elements to justify the E&M coding are documented, as well.    This has proven (so far) to be acceptable to our auditors.


Mark Soucy
Associate Professor
UT Health Science Center San Antonio
San Antonio TX
(210) 567-5893


2.  RE:Combining E&M and Psychotherapy Codes on a single encounter

Posted 10-29-2013 10:30 AM
Mark- Thanks so much for your post- it was very helpful.  Your documentation is right on target for audits and will help me update my progress notes.

Laurie Burke, PMHNP/CNS-BC
Psychiatric Nurse Practitioner
Family Behavioral Health Associates
Midlothian, Va 23112