How to Code for Stable Psychotherapy Patient

Q: I see a young patient every two weeks for 50 minutes, primarily for psychotherapy, and she is stable on her medication. I would like to know the most appropriate code(s) to use:

• Just 90834, since I’m primarily doing psychotherapy

• 99213 and 90836

• 99212 and 90836

A: Since you are monitoring the patient’s reaction to her medication as well as providing psychotherapy, it could be appropriate for you to bill for the E/M as well as the psychotherapy. Since the patient is primarily presenting for psychotherapy and is stable, and you are not considering a change in medications or other management options, you probably are doing no more than a 99212 level of E/M. In this scenario, 99212 and 90836 appear to be the appropriate choice.

APA members who have questions about reimbursement, coding, documentation, and other related practice issues may contact the Practice Management HelpLine at [email protected] or (800) 343-4671. ■