By Cyber Sense Billing Team · Published · Updated
Medication management is an E/M service
Psychiatric medication management visits are reported with the standard evaluation and management codes, most often the office and outpatient codes 99202–99215. The older psychiatry-specific medication management code was deleted years ago, yet some practices still treat these visits as a fixed flat service. Treating every follow-up as the same level ignores how much the work can vary, from a stable patient refilling a long-standing prescription to a patient with worsening symptoms, side effects, and safety concerns.
Since 2021, office E/M levels are selected based on either medical decision making or total time on the date of the encounter. History and exam must be medically appropriate but no longer drive the level.
Choosing the level by medical decision making
Medical decision making has three elements: the number and complexity of problems addressed, the amount and complexity of data reviewed and analyzed, and the risk of complications from patient management. Two of three elements must be met for a level. In psychiatry, risk is often the element that supports higher levels. Prescription drug management is an example of moderate risk in the AMA framework, and decisions such as hospitalization or drug therapy requiring intensive monitoring for toxicity can support high risk.
The note should show the reasoning: what problems were addressed, what changed, what alternatives were considered, and why the plan was chosen. A medication list without assessment does not show decision making.
Choosing the level by time
When time is used, count the total time the prescriber personally spent on the date of the visit, including reviewing records, examining the patient, counseling, ordering, documenting, and coordinating care. Time spent on a different date and time spent by clinical staff do not count. Document the total minutes and the activities. Time works well for long visits dominated by counseling or coordination, while MDM often fits short visits with high-risk decisions.
Adding psychotherapy to an E/M visit
When a prescriber also provides psychotherapy during the same visit, the add-on codes 90833, 90836, and 90838 can be reported with the E/M code. The psychotherapy must be significant and separately identifiable, with its own documented time and therapeutic interventions. The time spent on psychotherapy cannot be used to choose the E/M level when the E/M level is time-based, so many practices select the E/M level by MDM when psychotherapy is added. A note that simply says supportive therapy was provided, without time and content, will not support the add-on.
Telehealth and controlled substance considerations
Many medication management visits occur by telehealth. Payer rules for place of service, modifiers, and audio-only visits vary and should be checked per plan. Prescribing controlled substances by telehealth is also subject to federal and state rules that have changed through temporary extensions, so clinical and compliance staff should confirm current requirements separately from billing. From a claim perspective, the key is that the visit type, modality, and location match what the payer requires for the date of service.
Common denial and audit risks
Psychiatry E/M claims are questioned when levels are uniformly high or uniformly low, when psychotherapy add-ons appear on nearly every visit without separate time, when the rendering clinician is not credentialed with the plan, or when a behavioral health carve-out should have received the claim instead of the medical plan. Periodic internal review of a sample of notes against the AMA guidelines, plus clean payer routing at registration, reduces these risks.
Internal review that keeps coding consistent
A small, regular review program is more useful than an occasional large audit. Each month, select a handful of medication management visits per prescriber across different levels and compare the documented problems, data, and risk to the level billed. Look specifically at visits where psychotherapy add-ons were reported to confirm that separate time and interventions were documented, and at visits billed by time to confirm the total minutes were recorded and limited to the prescriber's own work on that date.
Share results with clinicians as education rather than discipline. Many under-coding problems come from prescribers who do substantial decision making but document it briefly, while over-coding often comes from templates that carry forward text from earlier visits. Adjusting templates so they prompt for the assessment and plan of each problem, the medications changed and why, and any safety considerations tends to improve both accuracy and clarity. Over several months, the distribution of E/M levels should reflect the real mix of stable and complex patients in the practice, which is the pattern payers expect to see.
Frequently asked questions
Can a PMHNP bill medication management with E/M codes?
Yes. Psychiatric nurse practitioners enrolled with the payer generally report the same office E/M codes, subject to state scope and payer rules. Some payers reimburse NPs at a different rate.
Should we use time or MDM for psychiatry visits?
Either is allowed for office E/M. Use whichever the documentation best supports. When adding a psychotherapy add-on, MDM is usually simpler because psychotherapy time cannot count toward E/M time.
Is prescription drug management always moderate risk?
In the AMA framework it is listed as an example of moderate risk, but the overall level still requires two of the three MDM elements to be met.
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This article is general information, not legal or coding advice. Always check current CPT®, ICD-10-CM, CMS and payer guidance. Questions? Contact us.