CPT DOCUMENTATION REQUIREMENTS FOR E/M CODE 99214
WITH AN ADD-ON PSYCHOTHERAPY SERVICE
When an E/M office visit is provided together with an add-on psychotherapy code (90833, 90836 or 90838), the E/M code must be documented based on elements, not time.
First, a chief complaint must be included in each note.
In addition, each 99214 note must include documentation of two of the following three elements: a detailed history, a detailed examination and medical decision making of moderate complexity. However, since typical psychiatric documentation will include an interval history and examination for each visit with an established patient, there is no need to document the third element, complexity, for a 99214 visit provided both history and examination are documented. In addition to the chief complaint, the treatment record must include the proper level of documentation of History of Present Illness (HPI), Review of Systems (ROS), Past, Family and/or Social History (PFSH) and the Psychiatric Examination.
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