Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Tuesday, November 27, 2012

E/M Psychoanalysis Note-Tuesday

Here's the second note of the week:

Name: Socrates     DOB: 469 BCE      Date of Service: 11.27.12

Start time: 2:30pm  Stop Time: 3:15pm.  Total Face Time: 45 minutes

CPT: 90836, E/M ?????

CC: F/U for "Self Knowledge"

Interval History: Patient's checking behavior has not worsened. He met with one of his students yesterday, about whom he has had some homosexual fantasies, and had a dream last night in which he was trapped in a cave where he could only see shadows. 

ROS: none

PFSH: The patient works closely with his students.


  • Speech-Greek
  • Thought processes-logical
  • Thought Content: Focussed on dream
  • Affect: Mildly Anxious
  • General Appearance: Wearing toga
  • Other: Uses intellectualization and reaction formation as defenses

Dx: Anxiety NOS, consider OCD

Current Meds: none

Labs: Ordered-none; reviewed-none

Allergies: Hemlock

Psychotherapy Note: Interpreted dream in the context of the patient's concerns regarding his homoerotic fantasies.


Continue psychoanalysis 4x/week

And here we go again with the coding:

The interval history has, maybe 1 or 2 elements, say associated symptoms (checking), and timing (an implicit "overnight"). In any case, it certainly doesn't have 4 elements, so it's a brief history.

There is no ROS.

And there is one element in PFSH.

So for the level of history,

Level of Hx
Problem Focussed
Extended Problem Focussed
1 System
2 Systems

we end up with "problem focussed".

Once again, the Exam has 6 elements.

And for the MDM:

You get 1 problem point for checking, an established, stable problem. 

There are 0 data points.

And the risk is low, for one stable, chronic illness.

Making the MDM straightforward.

In summary, then:

Level of Care
Problem Focussed
Extended Problem Focussed
Low Complexity
12 from 2 or more organ systems
Moderate Complexity
2 from each of 9 organ systems
High Complexity

This gives us a 99212 E&M code.  

Now, this was interesting as an exercise, but I don't really want to do this kind of careful review for every note I write. It would be easier to keep the note to a minimum and bill as a 99212, which most notes will probably turn out to be, anyway. But then, sometimes, it's possible to eke out a 99213, or even a 99214, and this makes a very real financial difference. 

So is it worth it to comb through every note? I don't know. Thoughts?


  1. You don't seem to be taking into account that the requirement is that the time spent in psychotherapy be distinct from the time spent on E/M services. Really an impossibility for psychotherapy, but that's what is called for to bill for 2 codes.

    The problem with undercoding to 99212 is that the patient gets reimbursed less if the criteria for 99213 were actually met.

    Even with your posts and charts, I still need an easier way to figure out what the E/M code is (I can hope?).

    It does seem you could ask a few questions regarding ROS or mental status to justify a higher code (I think).

    Also, I believe you can bill a simple psychotherapy code, like a non-MD, if there are no medications involved. I'm assuming that since Socrates is dead, he's not on Abilify.

  2. From what I understand from the talk I attended, the time for E/M and therapy can be interspersed. You don't need to have a separate x minutes of E/M time. There are different rules for when you're doing counseling, but I can't even remember what constitutes counseling.

    I also can't figure out a simpler way to determine the E/M code. Maybe I'll work on a quick method.

    And yes, you can bill like a non-MD, but that is also reimbursed less. If you use an MD CPT code, then you have to have an E/M code.

  3. Google the National Council's slide show on CPT codes:
    Major Changes – Psychotherapy
    and E/M Procedures
    > If patient receives medical E/M service and
    psychotherapy service on the same day by the same
    provider, report:
    • E/M code at the appropriate level AND
    • Psychotherapy add-on code (90833, 90836, 90838)
    > The two services must be significant and separately
    > A separate diagnosis is not required

  4. You may be right.

    But I attended a talk given by the lawyer for the NY State Psychiatric Association who pushed for this new coding system, and at the talk, someone asked exactly the question you're asking about the time distinction. His (the lawyer's) take on it, as I understand it, is that technically they are separate, but you don't need to denote during exactly which minutes of the session the E/M occurred, vs. when the CPT occurred. Nor do they have to occur discretely, since it's therapy. You just have to be sure that the total required time for each was met.

    He actually designed the note template, on which I based my note format, and he simply has checkboxes for 99212, 99213, 90833, and 90836, and then start time, stop time, and total face time. He didn't include a separate time for E/M vs. CPT. Since I got the impression he was responsible for drafting the law, I assume he was right. That may be my mistake. I would like to post the template he gave out, but since these were paid talks, I don't feel comfortable doing so.
    Also, his determination for 99212 vs. 99213 seems to be that 99213 has 1 to 3 elements of history. I think that simplifies things in terms of paperwork, but based on the the research I did for the posts, those are not the only distinctions, and it may even be possible to bump the note up to a 99214, which he didn't include as a possibility. Since the financial difference is very real, I feel like I have to make the best effort I can for my patients.

    Bottom line: I think nobody knows since this is brand new.

    Thanks for helping me try to hash this out.