CODING
“When crossing a river, remove your sandals.
When crossing a border, remove your crown.”
~White Hmong proverb
Medical Decision-Making Table APA / Quick Guide to 2021
Office/Outpatient E/M Services 99202-99215 Coding
https://www.psychiatry.org/getmedia/7400c009-7bf1-4269-808bb3dcd9b7758a/APA-Quick-Guide-to-2021-Office-Outpatient-EMServices-Coding-Changes.pdf
Code for ENTIRE day!
99212 (return) / 99202 (new within the last 3 years)
- 99212: Straightforward problems / no referrals, tests, etc.
99213 (return) / 99203
- Low complexity
o 2 or more self-limited or minor problem or
o 1 stable chronic illness (at least 1 year +) or
o 1 acute, uncomplicated illness
- Must meet 1 or 2 categories
o 1 - Tests and records ordered or reviewed.

Get credit for ordering OR reviewing.
o 2 – Independent historian
- Risk of complications or morbidity/mortality is low
99214 (return) /99204
- Moderate complexity
o 1 acute complicated problem
o 2 or more stable chronic conditions or
o 1 Undx new problem with uncertain prognosis or
o 1 acute illness with systemic sx (ex. ED with bradycardia) or
o 1 or more chronic illness with exacerbation, progression, or side
effects
- Collateral i.e. therapist, pharmacist, etc. either calling or reviewing
records, interpretating tests, etc.
- Risk of complication and or morbidity/mortality of pt
o Rx drug management
o Doesn’t have transportation, homeless, - dx or tx significantly
impacted by social determinants of health.
99215 (return) / 99205
- High complexity
o 1 or more chronic illness with severe exacerbation, progression
or side effects of tx. Ex. significant functional decline, severe
side effects or
o 1 acute or chronic illness or injury that poses a threat to life or
bodily function Ex. command hallucination or SI with plan.
o Tests order or review, document review or independent
historian or physician.
o Risk of complications – drug therapy requiring intensive
monitoring for toxicity, decision regarding hospitalization,
clozapine management, initiation of lithium or consideration of
inpatient behavioral health admission.
When Billing by Time
99212 – 10 to 19
99213 – 20 to 29
99214 – 30 to 39
99215 – 40 to 54

Treatment Plan * IMPORTANT *
Add On Codes
https://www.aacap.org/App_Themes/AACAP/docs/clinical_practice_center/business_of_pract
ice/cpt/2021-CPT-Code-Training.pdf
Assessments
96127 – screening code – PHQ9 etc. – Freq you can use varies with insurance companies
96161 – screening code - parent or caregiver – Freq you can use varies with insurance
companies
Substance Use
99406 – Smoking Cessation >3 min
99407 – Smoking Cessation >10 min
99408 – Screening / Counseling Intervention for Alcohol Misuse 15 min +
Prolonged Service Code Add On
New patient - 99205 60 – 74 min / Return patient 99215 40 – 54 min

Before/after seeing patient (not the day of the visit):
o Commercial Insurance only!
o 99358 – first hour
o 99359 – each additional 30 min

On day of visit:
o Not including Medicare!
o 99417 – Bill for each 15 min with or without direct pt care.
Psychotherapy Coding Video
https://ncpsych.memberclicks.net/assets/ENEWS/2021%20APA%20QuickGuide-to-2021-Office-Outpatient-EM-Services-Coding-Changes.pdf
Interactive Complexity
- 90785
o Complex
o CPS Report
o Parents / child argumentative
o Play therapy / or anything to help with communication.
o Need to have psychotherapy code.
o 90792 / 1st apt / diagnostic interview