What Are E/M Codes?

E/M codes, or Evaluation and Management codes, are a set of CPT codes to bill and document medical care services of medical physicians, such as psychiatrists, psychologists, and therapists. E/M codes help in assessing the extent and level of treatment provided during clinic visits according to such as history-taking, medical decision-making (MDM), and examination (where appropriate).

E/M codes are of vital importance for follow-up visit billing, medication management, and diagnostic visits in psychiatry and psychotherapy. Accurate E/M coding ensures proper reimbursement, medical billing rules compliance, and sufficient documentation of the patient's care. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) govern the codes to avoid discrepancies and vagueness in medical billing.

E and M Codes Definition and Importance

E and M CPT codes classify patient visits based on evaluation, history, physical examination (if done), and level of complexity of MDM. They are utilized by behavior health clinicians for therapy, psychiatric evaluation, and medication management. Psychiatrists and psychologists must document the symptoms, history, and risk factors of the patient to support the E and M codes billed for medical billing.
Misuse or under-documentation may lead to claim denial or audit. These codes exist to differentiate uncomplicated from complicated cases so that the providers will be reimbursed for the quality of care provided.

Understanding E/M Codes in Behavioral Health

• Evaluation and Management (E/M codes) are the most applicable CPT E/M codes therapists, psychologists, and psychiatrists use to bill patient encounters.

• The codes also acknowledge the level and extent of medical decision-making (MDM) in psychiatric services and psychotherapy.

• Accurate use of E and M codes gives compliance with E and M codes guidelines, proper billing, and proper reimbursement.

• Mental health professionals rely on E and M CPT codes to categorize their services and justify the level of care they have delivered.

• Well-documented E and M code medical billing ensures the physician equitable pay and reduces the chances of denial of claims. 

• These guidelines are made by the American Medical Association (AMA) and Centers for Medicare & Medicaid Services (CMS) to facilitate uniformity in medical billing methods in different specializations, i.e., psychiatry.

Key Components of E/M Codes in Psychiatry

These codes are defined on the basis of history-taking, medical decision-making (MDM), and, if so indicated, physical examination. Proper documentation of these factors ensures accurate billing and conformity to E and M code requirements.

1. History and Examination

A physical examination is not necessarily indicated in psychiatry but needs to be recorded when it is applicable (e.g., if the patient is experiencing medication side effects such as tremors, weight gain, or blood pressure fluctuations secondary to psychiatric medications). History-taking is an integral component of psychiatric E and M codes and involves taking a history on:

• Symptoms of presentation (e.g., mood disorders, depression, anxiety)

• Previous psychiatric history

• Family and social history

• Medication and treatment compliance

2. Medical Decision-Making (MDM)

Medical Decision-Making (MDM) is the most fundamental component of E/M coding in psychiatry, as it determines the level of complexity of the provided service. Three primary components of MDM are:

Number and Complexity of Problems Addressed

This refers to the severity and nature of the condition of the patient. For example, managing mild anxiety involves low complexity, while managing schizophrenia with active psychotic symptoms present involves high-complexity MDM due to possible risks.

Amount and Complexity of Data Reviewed

Evaluation of patient records, consultation with other health professionals (e.g., social workers, general practitioners, or specialists), and evaluation of test results contribute sophistication to MDM. The more data that need to be evaluated and synthesized into decision-making, the more sophisticated the level of MDM.

Risk of Patient Management

This quantifies the risk of the treatment options. Prescribing an SSRI for mild depression carries little risk, whereas adjusting medication of antipsychotic medications for a schizophrenic patient with suicidal thoughts is a far higher risk. These situations could require close monitoring or hospitalization, which will impact the E/M coding level.

E and M Codes for Psychiatry and Psychotherapy

Behavioral health professionals utilize some E and M codes for psychiatry to distinguish between evaluation/management services and psychotherapy. These E and M codes lists allow the professionals to categorize different levels of care and enable proper billing.

New Patient Visits

• 90791 – Psychiatric diagnostic evaluation (no medical services)

• 90792 – Psychiatric diagnostic evaluation (with medical services)

• 99202-99204 – Outpatient E and M codes outpatient services based on complexity

• 99241-99245 – Consultation services

Add-on Psychotherapy Codes (+90833, +90836, +90838)

These codes should be used only when the E/M base code (e.g., 99202–99205) is selected on the basis of Medical Decision Making (MDM). In such a situation, the time of psychotherapy is reported separately from the E/M service. As, these add-ons are specifically paired with E/M codes. The time thresholds are-

• +90833 – 16–37 minutes of psychotherapy

• +90836 – 38–52 minutes of psychotherapy

• +90838 – 53+ minutes of psychotherapy

Standalone Psychotherapy Codes (If only psychotherapy is provided)

• 90832 – 16–37 minutes

• 90834 – 38–52 minutes

• 90837 – 53+ minutes

Follow-up Visits

Commonly used for medication management, titration of treatment regimen, or management of comorbid conditions.

• 99212–99215 – E/M established patient office/outpatient visits

• Chosen on time or MDM

Family and Group Therapy Codes

• 90846 – Family therapy (without the patient)

• 90847 – Family therapy (with the patient)

• 90853 – Group therapy

E and M Codes New Patient vs. Established Patient

For E and M codes new patient, a psychiatrist or psychologist must conduct a comprehensive evaluation and determine a diagnosis. New patient visits generally require more extensive documentation, i.e., a complete psychiatric history, family history, and treatment planning. For established patients, the focus is on progress, medication management, and therapies. Established patient visits are low in weight of documentation but need to include clear MDM rationale to defend coding levels.

E and M Codes 2023 Updates

• The 2023 E and M codes and 2024 E and M codes updates brought significant modifications with the objective of streamlining documentation and coding processes for behavioral health professionals.

• These modifications enhance medical decision-making (MDM) as the dominant factor controlling E M codes in medical billing, consequently reducing the emphasis on history and physical exams.

• The updates also specify the criteria for selecting the right E and M CPT codes, enabling psychiatrists, psychologists, and therapists to bill accordingly for patient visits.

• The new guidelines for E and M codes also aim at minimizing redundant documentation, allowing providers to focus on clinically meaningful information regarding patients.

 These updates will improve efficiency in psychiatric care without compromising AMA and CMS compliance.

H2: Best Practices for Accurate E/M Coding in Psychiatry

1. Document Thoroughly –  Clearly document symptoms, patient reaction to treatment, and changes in medications.

2. Ensure Proper MDM Justification –  Report risk levels, complexity of treatment, and decision-making justification.

3. Use Appropriate E/M Levels – Avoid both overcoding and undercoding; match the complexity of the service with the correct E and M codes list.

4. Stay Updated on Coding Changes – Comply with AMA's E and M codes guideline for preventing claim denial.

Conclusion

Understanding what are E/M codes and how they are used in psychiatry ensures proper documentation and proper billing. By following guidelines and best practices for E and M codes, behavioral health care providers can optimize reimbursement while complying with requirements. 

Correct application of E and M codes in medical billing not only serves rightful reimbursement but also reduces audit and claim denials risk. With psychiatric treatment becoming increasingly complicated, E M code competency for psychiatry is required for therapists, psychiatrists, and psychologists providing mental health services.