Yes, You Can Get Paid for Medication Management

Betsy Nicoletti, MS


April 30, 2019

In This Article

The Coding Expert Answers Your Questions

Editor's Note: Betsy Nicoletti, MS, a nationally recognized coding expert, will take your coding questions via email and provide guidance on how to code properly to maximize reimbursement. Have a question about coding? Send it here.

In this column, Nicoletti addresses documenting for medication management and proper coding for Medicare wellness visits.

Coding for Medication Management

Question: As a psychiatrist, how do I bill for and document medication management? Are there different codes for short and long visits? Should I bill all of them at the same level?

Answer: There is no specific Current Procedural Terminology (CPT) code for a med check in the psychiatry section of the book anymore. When it was deleted, CPT instructed psychiatrists to use evaluation and management (E/M) codes for medication management. These are typically the established patient visit codes, 99211–99215. This is a CPT rule, used for all payers, including Medicare.

A psychiatrist, psychiatric nurse practitioner, or physician assistant may use the three key components (history, exam, and medical decision-making) or time to select the level of service, if medication management is the only service performed.

If using time to select a code, the typical time for 99212 is 10 minutes, 99213 is 15 minutes, 99214 is 25 minutes, and 99215 is 40 minutes. You would document, "I spent 15 minutes face-to-face with the patient, over half in counseling regarding his medications."

If the psychiatrist is billing an add-on psychotherapy code on the same day as medication management, select the code based on the key components, and use a psychotherapy code based on time. The time spent in medication management can't be included in the psychotherapy time.

Although in reality it is difficult to separate the services, that is the rule for when both medication management and psychotherapy are done on the same day. In this case, select the E/M code based on the key components, and document, "I spent 20 minutes in psychotherapy after providing medication management."


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