Evaluation and Management (E/M) coding is a cornerstone of mental health billing, especially when determining reimbursement for psychiatric assessments and follow-up care. The distinction between new and established patients directly influences the E/M code selection, documentation requirements, and reimbursement amounts. Below is a comprehensive guide tailored for mental health providers navigating this key aspect of coding compliance. If your services include both therapy and medication oversight, it’s worth reviewing the proper use of CPT code 90863 for pharmacologic management to ensure clean claims and correct documentation — especially when billing alongside psychotherapy.
Understanding E/M Codes
E/M codes describe the time, complexity, and documentation required for medical services. Commonly used E/M codes in mental health include:
- 99202–99205: New patient outpatient visits
- 99211–99215: Established patient outpatient visits
These codes are used when a provider performs a psychiatric evaluation or management service that involves more than just psychotherapy.
Definition of New vs. Established Patient
According to the AMA and CMS:
- New Patient: A patient who has not received any professional services from the provider or another provider of the same specialty within the same group in the past three years.
- Established Patient: A patient who has received professional services from the provider or another provider of the same specialty and group within the past three years.
Example: If a patient saw a psychiatrist in your practice two years ago, and is now seeing a different psychiatrist in the same group, they are considered established.
Many providers face confusion when billing for family sessions, especially regarding the presence or absence of the patient. A helpful overview on the difference between CPT codes 90846 and 90847 for family therapy can clarify when and how to use each code properly.
Key Differences in E/M Code Selection
| Criteria | New Patient (99202–99205) | Established Patient (99211–99215) |
| History/Exam Requirements | More comprehensive | Less comprehensive |
| Medical Decision Making | Typically more complex | Usually less complex |
| Time Requirements | Typically longer | Can be shorter |
| Reimbursement | Higher | Lower |
2021 Changes in E/M Guidelines
As of January 1, 2021, time and Medical Decision Making (MDM) are the primary components used for E/M code selection. This change simplifies coding by reducing the burden of documentation.
- Time-Based Coding: Total time spent on the day of the encounter (face-to-face and non-face-to-face).
- MDM-Based Coding: Focuses on complexity (number of problems, data reviewed, and risk).
When to Use E/M Codes in Mental Health
E/M codes are appropriate when a provider:
- Conducts an initial psychiatric diagnostic evaluation with medical components
- Adjusts medications
- Performs risk assessments
- Provides health counseling or evaluation beyond psychotherapy
They can also be billed in conjunction with psychotherapy (e.g., 90833, 90836, 90838) when medical services are provided.
For clinicians offering a wide range of assessments, managing billing across multiple codes can get complex. This advanced guide to billing psychological testing services provides deeper insights into bundling, documentation, and payer expectations.
Documentation Tips
- Clearly differentiate between medical management and psychotherapy services.
- For new patients, include detailed history, review of systems, and risk factors.
- For established patients, document ongoing management, medication response, and changes in condition.
- Use templates that reflect the 2021 E/M changes.
Common Mistakes to Avoid
- Misclassifying patients (new vs. established)
- Over-documenting or under-documenting for code-level selected
- Missing time logs for time-based billing
- Incorrect bundling of E/M with psychotherapy services
New York Mental Health Billing Tip:
NY Medicaid often requires authorization for extended sessions like 90837. Without it, claims may default to 90834 or be denied entirely.
Check out our New York Billing Services to ensure proper code use and faster payments.
Real-World Example
A psychiatric nurse practitioner sees a new patient for a 60-minute evaluation including full medical history, medication reconciliation, and risk assessment:
- Use 99205 (New Patient, high complexity, 60–74 minutes)
At a follow-up 3 weeks later, the same patient is seen for a 25-minute medication management check-in:
- Use 99214 (Established Patient, moderate complexity, 30–39 minutes)
Reference
Additional Considerations for Mental Health Providers
Telehealth Services
Since the COVID-19 pandemic, the use of E/M codes in telehealth has increased dramatically. CMS and many commercial payers now allow E/M codes to be billed for telehealth visits. Ensure that:
- Services meet HIPAA-compliant telehealth standards
- Time or MDM criteria are met
- Proper modifiers (e.g., 95) and place of service codes are used
Coordination with Psychotherapy Codes
Mental health providers often blend medical and therapeutic services. When both are provided:
- Use an E/M code plus an add-on psychotherapy code
- Document both time and content separately
- Justify medical necessity for each
Psychiatric Collaborative Care Model (CoCM)
For practices using a team-based model involving primary care and psychiatric consultants, consider using:
- 99492–99494 for psychiatric CoCM billing
These codes are distinct from traditional E/M but still require robust documentation.
Final Thoughts
Understanding and applying E/M codes correctly is crucial for mental health providers. The distinction between new and established patients, combined with proper documentation and code selection, ensures timely reimbursement and reduces compliance risks. At Global Tech Billing LLC, we specialize in helping mental health clinics and solo providers navigate these coding nuances for optimal revenue outcomes.
Frequently Asked Questions (FAQs)
1. Can I bill an E/M code alone for a mental health visit?
Yes, if the visit involves only medical evaluation/management (e.g., medication checks, risk assessments).
2. What if I provide both therapy and med management?
Use both the E/M code and a corresponding psychotherapy add-on (e.g., 90833).
3. Can I use E/M codes for telehealth services?
Yes, if payer policies permit and documentation meets time or MDM criteria.
4. How do I know which code to select?
Base your selection on the total time spent or the complexity of medical decision-making.
5. What happens if I misclassify a patient as new or established?
It can lead to denials or audits. Always verify patient status using past records.
