Would a visit for a patient with recurrent moderate major depressive disorder, starting a new medication (fluoxetine) and requiring close follow-up, be coded as a 99213 or 99214?

Evaluation and Coding for Major Depressive Disorder Visit

This visit should be coded as a 99214 due to the moderate complexity medical decision-making involved in initiating antidepressant medication for recurrent, moderate major depressive disorder.

Assessment of Medical Decision Making Complexity

Problem Complexity

• Recurrent, moderate major depressive disorder represents a moderate-level problem requiring prescription drug management 1
• The patient has a history of self-harm (cutting) which increases the risk profile of this encounter 1
• Starting medication for depression requires careful consideration of side effects, dosing, and follow-up planning 1, 2

Data Review

• Review of patient's psychiatric history, including previous counseling attempts with "moderate improvement" 1
• Assessment of risk factors including history of self-harm behaviors 1
• Evaluation of current symptoms to determine appropriate treatment approach 1

Risk Assessment

• Moderate risk due to:
  • Prescription of a new medication (fluoxetine) requiring monitoring 2
  • History of self-harm behaviors requiring risk assessment 1
  • Need for close follow-up (scheduled in 2 weeks) 2
  • Patient education regarding medication side effects and monitoring 1

Key Components Supporting 99214 Coding

Medication Management

• Initiation of fluoxetine 10mg daily represents prescription drug management for a chronic condition 2
• Low-dose initiation is appropriate for this patient population to minimize side effects while establishing treatment 2, 3
• Detailed patient education was provided regarding potential side effects and monitoring requirements 1

Follow-up Planning

• Short-term follow-up (2 weeks) was scheduled, which is consistent with best practices when initiating antidepressant therapy 2
• This follow-up timeline allows for early assessment of medication tolerability and effectiveness 4
• Early follow-up is particularly important given the patient's history of self-harm 1

Risk Management

• The provider appropriately assessed suicide risk (patient denies plans) 1
• Both patient and parent were educated about side effects and symptoms requiring notification 1
• Clear follow-up instructions were provided 2

Why This Is Not a 99213

• The visit exceeds 99213 requirements due to:
  • Moderate complexity medical decision making involving prescription drug management for a moderate-level psychiatric condition 1
  • Risk assessment and management for a patient with history of self-harm 1
  • Detailed medication counseling and education provided to both patient and parent 1
  • Planned close follow-up to monitor treatment response and potential adverse effects 2

Common Coding Pitfalls to Avoid

• Don't undercode based solely on the brief nature of the documentation; the medical decision making complexity supports 99214 1
• The initiation of psychotropic medication with risk assessment and monitoring requirements meets the threshold for moderate complexity decision making 1, 2
• The combination of recurrent depression, history of self-harm, and new medication management justifies the higher level code 1

Documentation Recommendations

• Ensure documentation clearly reflects:
  • Assessment of suicide risk and safety planning 1
  • Rationale for medication selection and dosing 2
  • Details of patient/parent education provided 1
  • Specific follow-up plans and monitoring parameters 2