E/M Coding for Psychiatry

E/M Coding for Psychiatry: Cutting Through the Confusion and Making Sure You Get the Reimbursement You Deserve

In 1995, CMS developed documentation standards (Evaluation and Management Coding Guidelines) to measure the level of service provided by a health care practice. These guidelines were developed to ensure proper coding methodology for medical billing based on the level of service provided by the medical specialist. The following components are used to determine the level of E/M service: History, Examination, Medical Decision Making, Nature of Presenting Problem, and Time.

Psychiatry as a specialty has long been excluded from the use of Evaluation and Management Coding Guidelines. As a result, psychiatric practices haven’t been fairly reimbursed for services by insurance companies.

Most providers have not used E/M billing codes, and when they did use the codes, they were often challenged by the insurance payers. The insurance companies’ policy manuals misinformed providers by mandating the use of a “mental health only” billing platform. Healthcare billing and coding professionals, unfortunately, have billed in accordance with the insurance companies’ preferences, which led to a significant reduction in financial reimbursement for the psychiatrists.

Finally, things are changing. CPT codes have been modified to eliminate a number of the mental health-specific codes. And CMS mandated the use of evaluation and management-based coding effective January 01, 2013. This means psychiatric practices are able to use the same billing codes as other specialties. While this change created some consternation within the mental health community, once it was implemented it became clear that using evaluation and management CPT codes results in higher and more accurate levels of insurance reimbursement.

PatientTrac has been ready for E/M billing guidelines — and providing effective clinical documentation supporting E/M — since 2007.

We could not have foreseen this change in 2007. But we have always believed that psychiatrists should be paid at the highest levels of reimbursement, just like other specialists. Many of our clients have been documenting within E/M guidelines for years. We are delighted to see psychiatry as a specialty finally being fairly compensated without “mental health” reductions. And we remain committed to ensuring that our clients receive the highest level of reimbursement possible for the services they provide.

Our clients always have up-to-date information on CPT code changes. PatientTrac EMR has real-time Evaluation and Management verification, letting you know which components have been completed in EMR and what billing level a visit qualifies for. No under coding for our clients!

E/M elements and guidelines for E/M calculation

  • HISTORY
  • REVIEW OF MEDICAL SYSTEMS
  • LEVEL OF EXAM
  • MEDICAL DECISION MAKING
  • LEVEL OF RISK

ELEMENTS OF HISTORY

TYPE OF HISTORYCHIEF COMPLAINTHPIHPIPFSH
Problem FocusedRequiredBriefN/AN/A
Expanded Problem FocusedRequiredBriefProblem PertinentN/A
DetailedRequiredExtendedExtendedPertinent
ComprehensiveRequiredExtendedComplete, including ten systems are WNLComplete

In PatientTrac, the History component, named Psychiatric Review of Systems@, is designed not only to meet the HPI element of the E/M codes but also to provide an expansive review of the mental health systems in documenting patient's subjective state. (See Adult or Child Psychiatry).

There are two types of HPI:

1). Brief, documentation of one to three HPI elements.
2). Extended, documentation of at least four HPI elements; status of at least three chronic or inactive conditions.

Past, Family, Social History (PFSH)

  • Past history including experiences with illnesses, operations, injuries, and treatments
  • Family history including a review of medical events, diseases, and hereditary conditions that may place him or her at risk
  • Social history including an age appropriate review of past and current activities
  • Past Psychiatric History
  • Family Psychiatric History
  • Chief Complaint

There are two types of PFSH:

1). Pertinent, review of the history areas directly related to the problem(s) identified in the HPI. 2). Complete, review of two or all three of the areas, depending on the category of E/M service.

Complete Past, Family, Social History (PFSH)

A complete PFSH requires a review of all three history areas for services that, by their nature, include a comprehensive assessment or reassessment of the patient. A review of two history areas is sufficient for other services. At least one specific item from two of the three history areas must be documented for a complete PFSH for the following categories of E/M services: Office or other outpatient services, established patient; Emergency department; Domiciliary care, established patient; Home care, established patient.

Review of Medical Systems (ROS)

ROS is an inventory of body systems obtained by asking a series of questions in order to identify signs and/or symptoms that the patient may be experiencing or has experienced. In PatientTrac, the following systems are recognized: Constitutional, Eyes, Ears, Nose, Mouth, Throat, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal, Integumentary (skin and/or breast), Neurological, Endocrine, Hematologic/Lymphatic, and Allergic/Immunologic.

Where CMS guidelines specifically permit the documentation of “WNL”, or “we never looked”, for the medical review of systems, PatientTrac denotes a WNL documentation as “A review of Breast, Cardiovascular, Constitutional, Endocrine, ENT, Eyes, Gastrointestinal, Genitourinary, Gynecologic, Hematologic/Lymphatic, Integumentary, Musculoskeletal, Neurological, Pain, Respiratory medical systems was otherwise non-contributory.”

ROS Scoring

1)  Problem pertinent, inquires about the system directly related to the problem identified in the HPI. 2)  Extended, inquires about the system directly related to the problem(s) identified in the HPI and a limited number (two to nine) of additional systems. 3)  Complete, inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional (minimum of 10) body systems.

LEVEL OF EXAM: Perform and Document

Problem Focused: One to five elements identified by a bullet. Expanded Problem Focused: At least six elements identified by a bullet. Detailed: At least nine elements identified by a bullet. Comprehensive: Perform all elements identified by a bullet, document every element in a shaded box and at least one element in an unshaded box below.

System/Body AreaElement of Examination
ConstitutionalMeasurement of any three of the following seven vital signs:
sitting or standing blood pressure, supine blood pressure, pulse rate and regularity, respiration, temperature, height, weight (may be measured and recorded by ancillary staff)
General appearance of patient (e.g., development, nutrition, body habitus, deformities, attention to grooming)
MusculoskeletalAssessment of muscle strength and tone (e.g., flaccid cog wheel, spastic) with notation of any atrophy and abnormal movements
Examination of gait and station
PsychiatricDescription of speech including: rate; volume; articulation; coherence; and spontaneity with notation of abnormalities (e.g., preservation, paucity of language)
Description of thought processes including: rate of thought; content of thoughts (e.g., logical vs. illogical, tangential); abstract reasoning; and computation
Description of association (e.g., loose, tangential, circumstantial, intact)
Description of abnormal or psychotic thoughts including: hallucinations; delusions; preoccupation with violence; homicidal or suicidal ideation; and obsessions
Description of the patient’s judgment (e.g., concerning everyday activities and occasional situations) and insight (e.g., concerning psychiatric condition)

In PatientTrac EMR, the evaluation and management bullets are calculated automatically during the documentation for both accurate coding and billing AND E/M audit protection.

The Mental Status Examination in PatientTrac EMR was designed by practicing psychiatrists and it provides a comprehensive format for documenting the MSE and ensures the provider is aware of the necessary completed elements for each system and the calculated bullet value. The calculation is not based on a one- to-one calculation but instead systems may have multiple data elements for a bullet calculation of (1). For example:

Appearance, Remarkable Features, Habitus, Patient Appears, Nutritional Status(1) Bullet
Muscle Strength and Muscle Tone(1) Bullet
Gait and Station(1) Bullet
Orientation (1) Bullet
Speech and Voice(1) Bullet
Thought Process, Proverb and Similarities(1) Bullet
Associations(1) Bullet
Insight and Judgment(1) Bullet
Naming and Repetition(1) Bullet
Mood and Affect(1) Bullet
Registration, Serial 7 and Spell(1) Bullet
Delusions, Hallucinations, Suicidal Ideation and Homicidal Ideation(1) Bullet
Fund of Knowledge(1) Bullet
Remote Memory and 5 minute recall(1) Bullet
Vital Signs(1) Bullet

Medical Decision Making

Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option, which is determined by considering following factors:
  • The number of possible diagnoses and/or the number of management options that must be considered;
  • The amount and/or complexity of medical records, diagnostic tests, and/other information that must be obtained, reviewed and analyzed;
  • The risk of significant complications, morbidity, and/or mortality as well comorbidities associated with the patient's presenting problem(s), the diagnostic procedure(s), and/or the possible management options.
Type of Decision MakingNumber of Dx or Management OptionsAmount and/or Complexity of Data to Be ReviewedRisk of Significant Complications, Morbidity and/or Mortality
Straightforward *MinimalMinimal or NoneMinimal
Low Complexity *LimitedLimitedLow
Moderate Complexity *MultipleModerateModerate
High Complexity *ExtensiveExtensiveHigh

* Note that to qualify for a given type of medical decision making, two of the three elements must either be met or exceeded. Appendix C of the 2003 CPT manual 4 provides some pertinent examples. The application of these criteria to psychotherapy or counseling visits is not intuitively obvious. Even though examples listed in the CPT manual have particular specialties identified, applicability is not limited to any particular specialty. Example 1 is for code 99204, an initial office visit for a 17-year-old adolescent girl with depression. Example 2 is for code 99214, an office visit for a 52-year-old, established male patient, with a 12-year history of bipolar disorder responding to lithium carbonate and brief psychotherapy. Both psychotherapy and a prescription are provided. The third example given is for code 99215, an office visit for a 27-year-old, established female patient with bipolar disorder who was stable on treatment with lithium carbonate and monthly supportive psychotherapy but who has developed symptoms of hypomania. (Other examples of 99215 indicate that high complexity MDM would be justified by the presence of hallucinations, severe depressive symptoms requiring an urgent visit, or comorbid panic attacks related to drug abstinence). No examples are provided for psychiatry services for codes 99212–13.

Level of RiskPresenting Problem(s)Diagnostic Procedure(s) OrderedManagement Options Selected
MinimalOne self-limited or minor problemVenipuncture; EKG; urinalysisRest
LowTwo or more self-limited or minor problems;
One stable chronic illness;
Acute uncomplicated illness
Arterial punctureOTC drugs
ModerateOne or more chronic illnesses with mild exacerbation, progression, or side effects;
Two or more stable chronic illnesses;
Undiagnosed new problem with uncertain prognosis;
Acute illness with systemic symptoms
Prescription drug management
HighOne or more chronic illnesses with severe exacerbation, progression, or side effects;
Acute or chronic illnesses that pose a threat to life or bodily function
Drug therapy requiring intensive monitoring for toxicity
Problem Points Data Points Risk Complexity of Medical Decision Making
0-10-1MinimalStraightforward
22LowLow
33ModerateModerate
44HighHigh

How to apply calculations

New Patient Office

  • 99201 +

    Chief ComplaintYES
    MSE Exam1-5 bullets
    HPIBrief (1-3 elements or 1-2 chronic conditions)
    PFSHN/A
    Review of SystemsN/A
    Medical DecisionStraightforward
  • 99202 +

    Chief ComplaintYES
    MSE ExamAt least 6 bullets
    HPIBrief (1-3 elements or 1-2 chronic conditions)
    PFSHN/A
    Review of SystemsProblem pertinent (1 system)
    Medical DecisionStraightforward
  • 99203 +

    Chief ComplaintYES
    MSE ExamAt least 9 bullets
    HPIExtended (4 elements or 3 chronic conditions)
    PFSHPertinent (1 element)
    Review of SystemsExtended (2-9 systems)
    Medical DecisionLow
  • 99204 +

    Chief ComplaintYES
    MSE ExamAll bullets in Constitutional and Psychiatric boxes and 1 bullet in Musculoskeletal box
    HPIExtended (4 elements or
    3 chronic conditions)
    PFSHComplete (2 elements (est) or
    3 elements (new))
    Review of SystemsComplete
    (10-14 systems)
    Medical DecisionModerate
  • 99205 +

    Chief ComplaintYES
    MSE ExamAll bullets in Constitutional and Psychiatric boxes and 1 bullet in Musculoskeletal box
    HPIExtended (4 elements or
    3 chronic conditions)
    PFSHComplete 3 elements (new)
    Review of SystemsComplete
    (10-14 systems)
    Medical DecisionHigh
  • 1

Established Patient Office

  • 99212 +

    Chief ComplaintYES
    MSE Exam1-5 bullets
    HPIBrief (1-3 elements or 1-2 chronic conditions)
    PFSHN/A
    Review of SystemsN/A
    Medical DecisionStraightforward
  • 99213 +

    Chief ComplaintYES
    MSE ExamAt least 6 bullets
    HPIBrief (1-3 elements or 1-2 chronic conditions)
    PFSHN/A
    Review of SystemsProblem pertinent (1 system)
    Medical DecisionLow
  • 99214 +

    Chief ComplaintYES
    MSE ExamAt least 9 bullets
    HPIExtended (4 elements or 3 chronic conditions)
    PFSHPertinent (1 element)
    Review of SystemsExtended (2-9 systems)
    Medical DecisionModerate
  • 99215 +

    Chief ComplaintYES
    MSE ExamAll bullets in Constitutional and Psychiatric boxes and 1 bullet in Musculoskeletal box
    HPIExtended (4 elements or 3 chronic conditions)
    PFSHComplete (2 elements)
    Review of SystemsComplete (10-14 systems)
    Medical DecisionHigh
  • 1

Initial Hospital/PHP

  • 99221 +

    Chief ComplaintYES
    MSE ExamAt least 9 bullets
    HPIExtended (4 elements or 3 chronic conditions)
    PFSHPertinent (1 element)
    Review of SystemsExtended (2-9 systems)
    Medical DecisionStraightforward
  • 99222 +

    Chief ComplaintYES
    MSE ExamAll bullets in Constitutional and Psychiatric boxes and 1 bullet in Musculoskeletal box
    HPIExtended (4 elements or 3 chronic conditions)
    PFSHComplete ( 3 elements)
    Review of SystemsComplete (10-14 systems)
    Medical DecisionModerate
  • 99223 +

    Chief ComplaintYES
    MSE ExamAll bullets in Constitutional and Psychiatric boxes and 1 bullet in Musculoskeletal box
    HPIExtended (4 elements or 3 chronic conditions)
    PFSHComplete ( 3 elements)
    Review of SystemsComplete (10-14 systems)
    Medical DecisionHigh
  • 1

Subsequent Hospital/PHP

  • 99231 +

    Chief ComplaintYES
    MSE Exam1-5 bullets
    HPIBrief (1-3 elements or 1-2 chronic conditions)
    PFSHN/A
    Review of SystemsN/A
    Medical DecisionStraightforward
  • 99232 +

    Chief ComplaintYES
    MSE ExamAt least 6 bullets
    HPIBrief (1-3 elements or 1-2 chronic conditions)
    PFSHN/A
    Review of SystemsProblem pertinent (1 system)
    Medical DecisionModerate
  • 99233 +

    Chief ComplaintYES
    MSE ExamAt least 9 bullets
    HPIExtended (4 elements or 3 chronic conditions)
    PFSHPertinent (1 element)
    Review of SystemsExtended (2-9 systems)
    Medical DecisionHigh
  • 1
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