CPT and ICD-10 Coding for Psychiatric Visit
For this clinical encounter, bill CPT 99214 (or 99213 depending on complexity) for the established patient office visit with medication management, CPT 90834 for the 45-minute psychotherapy session, and use ICD-10 codes F32.0 (mild major depressive disorder, single episode) and F41.1 (generalized anxiety disorder).
CPT Codes
Office Visit Code
- CPT 99213 or 99214: Established patient office visit
- The 15-minute medication management and brief counseling component requires evaluation of the visit's complexity based on medical decision-making and history/examination components 1
- 99214 is appropriate if moderate complexity medical decision-making is documented (adjusting psychiatric medications typically qualifies)
- 99213 if lower complexity
- Time alone should NOT be the primary determinant unless counseling dominates >50% of the encounter 1
Psychotherapy Code
- CPT 90834: Individual psychotherapy, 45 minutes
- This is the standard code for 38-52 minute psychotherapy sessions
- Can be billed separately from the E/M visit when both services are provided and documented
Important coding rule: When billing both an E/M code and psychotherapy code on the same day, ensure documentation clearly separates the medication management/medical evaluation from the psychotherapy component.
ICD-10 Codes
Primary Diagnoses
F32.0: Major depressive disorder, single episode, mild
- Use F32.0 for mild severity
- If recurrent episodes, use F33.0 instead
- If moderate severity, use F32.1 (single) or F33.1 (recurrent)
- If severe, use F32.2 (single) or F33.2 (recurrent)
F41.1: Generalized anxiety disorder
- This is the specific code for GAD 2
- List as secondary diagnosis if depression is the primary focus
Additional Consideration
- Z71.9: Counseling, unspecified (if general counseling beyond psychotherapy is provided)
- However, this is typically not needed when 90834 is billed
Documentation Requirements
To support these codes, your documentation must include 3, 4:
For the E/M component (99213/99214):
- Chief complaint
- Relevant history elements
- Mental status examination findings
- Medical decision-making regarding medication management
- Time spent if using time-based coding
For psychotherapy (90834):
- Duration of session (document 45 minutes)
- Therapeutic techniques used
- Patient's response to intervention
- Progress toward treatment goals
Common pitfall: Failing to document the psychotherapy session separately from medication management can result in claim denials. The services must be distinct and separately identifiable.