What is the minimum time Evaluation and Management (E/M) time code for an initial psychiatric evaluation?

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Last updated: May 16, 2025View editorial policy

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From the Guidelines

The minimum time requirement for an initial psychiatric evaluation is not explicitly stated in the provided evidence, but based on the available information, the minimum time for an initial evaluation can be inferred to be at least 45 minutes for a detailed and moderately complex evaluation, as indicated by CPT code 99204, which requires more than half of the time spent counseling 1.

Key Points to Consider

  • The provided evidence discusses various CPT codes for different levels of evaluation and management services, including those for new and established patients, as well as for prolonged services 1.
  • For initial evaluations, codes such as 99201-99205 are relevant, with 99204 being used for detailed and moderately complex evaluations taking at least 45 minutes, and more than half of this time spent counseling 1.
  • It's crucial to document the total face-to-face time spent with the patient and ensure it meets the threshold for the chosen CPT code, including time for history taking, mental status examination, diagnosis formulation, and treatment planning 1.
  • The evidence emphasizes the importance of proper documentation for reimbursement, highlighting the need to clearly reflect the time spent and components of the evaluation performed 1.

Relevant CPT Codes

  • 99204: Used for evaluations performed by the physician that are detailed and moderately complex or take at least 45 min (with more than half spent counseling) 1.
  • 99205: Used for evaluations that are comprehensive and highly complex or take 60 min (with more than half spent counseling) 1.
  • 99354 and 99355: Used for prolonged face-to-face services, with 99354 covering the first 30-74 minutes and 99355 for each additional 30 minutes 1.

From the Research

Minimum Time E/M Time Code for Initial Psych Evaluation

  • The minimum time for an initial psych evaluation is not explicitly stated in the provided studies 2, 3, 4, 5, 6.
  • However, study 6 mentions that the average and median session times for text-based mental health support sessions were 40 and 45 minutes, respectively.
  • It is also noted in study 6 that on-demand sessions were shorter (37.9 minutes) than scheduled sessions (43.5 minutes) 6.
  • Study 3 discusses the psychiatric evaluation of agitated patients, which can be a 2-step process, but does not provide specific time requirements for the initial evaluation 3.
  • Study 2 defines the components of a comprehensive psychiatric evaluation, including patient interview and observations of the patient's behavior, but does not specify a minimum time requirement 2.
  • Studies 4 and 5 discuss the importance of a thorough medical evaluation and the challenges of evaluating psychiatric patients in emergency settings, but do not provide specific time guidelines for initial psych evaluations 4, 5.

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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