Looking for clarification on billing an add-on psychotherapy code with E/M for med management. Right now, our docs are reporting total visit time, as well as time doing psychotherapy. So for example, he may document that he spent a total of 22 minutes with the patient, with 16 minutes of that doing psychotherapy. My understanding is that anything done to get the E/M level cannot be used towards the psychotherapy time, which leaves us with 6 minutes that was spent doing med management. Because so little time was spent doing the med management, I would code this as a 99211 with 90833 as an add-on.

The provider now has me second-guessing myself. He stated that he should still get the 99213 for the content of his medication management, as well as the 90833 for the psychotherapy, and that time should not play a factor into deciding the E/M level. Side note, the documentation is VERY minimal. A few sentences: Mood is good. Anxiety is low. Sleep is ok. No stressors. Then his normal ROS & Exam, which again is very minimal.

Do I bill the E/M based on content, or based on the time left after subtracting the time spent on psychotherapy?

Also, I’m the only BH coder at our facility, and don’t have many resources to bounce questions off of. Would anyone be willing to be available for questions as they arise?

Thank you all so much!