How do I bill for a session that includes both psychotherapy and medical evaluation and management, such as medication management, for a patient with chronic medical conditions or complex mental health needs?

Billing for Combined Psychotherapy and Medication Management

When providing both psychotherapy and medical evaluation/management (E&M) in the same session, you must use add-on psychotherapy codes (90833,90836, or 90838) appended to the primary E&M code (99211-99215 for established patients, 99201-99205 for new patients), with the E&M code listed first as the primary service. 1, 2

Understanding the Coding Structure

Primary vs. Add-On Code Hierarchy

• The E&M code must be reported as the primary code, followed by the add-on psychotherapy code, regardless of which service consumed more time or clinical focus 2
• This coding structure reflects Medicare's requirement that medical services take precedence in combined billing, even when psychotherapy is the dominant therapeutic intervention 2
• Clinical psychologists and clinical social workers cannot bill these combined codes (90833,90836,90838) under Medicare rules, as they are restricted to physicians, physician assistants, nurse practitioners, clinical nurse specialists, and nurse-midwives 3

Selecting the Appropriate Add-On Psychotherapy Code

• 90833: Add-on code for approximately 16-37 minutes of psychotherapy when combined with E&M 1
• 90836: Add-on code for approximately 38-52 minutes of psychotherapy when combined with E&M 1
• 90838: Add-on code for 53 minutes or more of psychotherapy when combined with E&M 1

Documentation Requirements

E&M Component Documentation

• Document all required E&M elements systematically: chief complaint, history of present illness, review of systems, past medical/psychiatric/family/social history, physical examination findings relevant to medication management, and medical decision-making complexity 1, 2
• Medical decision-making complexity should address: number of diagnoses or management options, amount and complexity of data reviewed, and risk of complications or morbidity 1
• Use templates with checklists during patient examinations to ensure all required E&M elements are captured without disrupting the therapeutic process 1

Psychotherapy Component Documentation

• Document the psychotherapy separately from the medical E&M, including: specific therapeutic techniques used, patient's response to interventions, progress toward treatment goals, and time spent in psychotherapy 1, 2
• Maintain HIPAA-protected psychotherapy notes separately for highly sensitive personal information that should not be part of the general medical record 2
• The general medical record should contain sufficient psychotherapy documentation to justify the add-on code without including deeply personal material that could compromise privacy in shared electronic health systems 2

Time-Based Billing Considerations

• Total encounter time includes both E&M and psychotherapy components, but you must separately track time spent on each activity 1
• The E&M code selection can be based on either time (when counseling/coordination of care dominates >50% of the encounter) or complexity of medical decision-making 1
• When using time-based E&M coding, document the total face-to-face time and specify that >50% was spent on counseling or coordination of care 1

Common Clinical Scenarios

Medication Management with Brief Supportive Therapy

• If providing 20 minutes of medication review/adjustment plus 20 minutes of supportive psychotherapy: Bill 99213 or 99214 (depending on complexity) + 90833 1
• Document medication changes, side effects, adherence issues, and laboratory monitoring in the E&M portion 1

Intensive Psychotherapy with Medication Monitoring

• If providing 45 minutes of cognitive-behavioral therapy plus 15 minutes of medication review: Bill 99213 or 99214 + 90836 1
• Even though psychotherapy dominated the session, the E&M code must be listed first per coding requirements 2

Crisis Intervention with Medication Adjustment

• Crisis care can be billed using standard E&M codes with add-on psychotherapy codes when both medical and psychotherapy services are provided 1
• Document the crisis nature, immediate interventions, safety assessment, and medication changes 1

Critical Pitfalls to Avoid

• Never bill standalone psychotherapy codes (90832,90834,90837) when you've also provided medication management - this constitutes incorrect coding and potential fraud 1
• Avoid using computers insensitively during sessions, as this can damage therapeutic rapport while you're trying to document E&M requirements 2
• Do not use 90792 (diagnostic evaluation with medical services) for follow-up visits - this code is only for initial diagnostic evaluations 3
• Ensure your documentation supports the level of E&M code selected - upcoding without appropriate documentation can trigger audits 1

Telemedicine Considerations

• Combined psychotherapy and medication management can be provided via telemedicine using the same coding structure (E&M + add-on psychotherapy codes) 3
• Medicare requires real-time interactive audio and video telecommunications for these services 3
• The patient must be located at an eligible originating site (physician office, hospital, rural health clinic, federally qualified health center, skilled nursing facility, or community mental health center) in a rural HPSA or non-MSA area, with limited exceptions 3

Coordination with Other Providers

• When comanaging patients with other mental health professionals, clearly delineate roles and responsibilities regarding who bills for which services 3
• Document communication with other providers and specify case coordination responsibilities 3
• Maintain involvement in follow-up even after referring to specialists, as this supports billing for ongoing medication management 3