Psychiatry · Coding

Medical Decision Making — Outpatient Psychiatric Encounters

Select the encounter type, then click the clinical facts that apply. The tool calculates office/outpatient MDM, compares qualifying E/M time, suggests psychiatric diagnostic or psychotherapy codes, and builds a documentation summary.

1. Choose the encounter pathway

Do not combine incompatible pathways. 90833, 90836, and 90838 are psychotherapy add-on codes used with a separately reportable E/M service and are not selected solely because counseling occurred.

2. E/M encounter details

Patient statusQualifying E/M time (min, excl. psychotherapy)Distinct psychotherapy minutes

When billing an E/M code with a psychotherapy add-on, do not count psychotherapy time toward time-based E/M selection.

3. Problems addressed

Select conditions actively evaluated or managed today — not every diagnosis on the problem list.

Straightforward1 self-limited or minor problemBrief resolving situational complaint requiring little management.Low1 stable chronic psychiatric illnessStable ADHD, MDD, GAD, PTSD, OCD, insomnia, or bipolar disorder.Low1 acute uncomplicated illness or problemUncomplicated adjustment disorder or short-term insomnia.Moderate2 or more stable chronic illnessesADHD plus anxiety; bipolar disorder plus PTSD; OCD plus insomnia — when both are addressed.ModerateChronic illness with exacerbation, progression, or treatment side effectsWorsening depression, PTSD flare, increased mania, stimulant adverse effects, antipsychotic side effects.ModerateNew undiagnosed problem with uncertain prognosisPossible bipolar, psychotic, autism-spectrum, neurocognitive, or other evolving disorder.ModerateAcute illness with systemic symptomsUse only when meaningful systemic manifestations are present.HighSevere exacerbation or progression of a chronic illnessSevere mania, psychosis, or depression requiring high-intensity management.HighCondition posing a threat to life or bodily functionAcute suicidal intent, dangerous psychosis, catatonia, delirium, or severe medication toxicity when actively managed.

Problems level: Straightforward

4. Data reviewed and analyzed

Do not count the same item twice merely because it was ordered and later reviewed.

Category 1

Unique external notes/documents reviewed

Hospital, PCP, neurology, therapist, IEP/504.

Unique test results reviewed

CBC, CMP, TSH, A1c, UDS, EKG, imaging, neuropsych.

Unique tests ordered

CBC, CMP, serum drug level, TSH, UDS, EKG, pregnancy test.

Assessment required an independent historianParent, guardian, spouse, caregiver, or group-home staff when the patient could not provide a complete reliable history.

Category 2

Independent interpretation of a test performed by another clinicianNot merely reading the report and not separately billing the interpretation.

Category 3

Management or test interpretation discussed with an external physician/QHP or appropriate sourceA direct professional discussion; simply reading a note does not qualify.

Data level: Straightforward

5. Risk of management

This is the risk created by the management decision — not simply symptom severity or suicide-screen score.

StraightforwardNo active treatment or minimal managementObservation or reassurance only.LowOTC medication, behavioral intervention, or low-risk supportive planSleep hygiene, exercise, routine behavioral recommendations, OTC options.ModeratePrescription drug managementStarting, continuing after assessment, adjusting, tapering, stopping, or monitoring a prescription medication.ModerateTreatment significantly limited by social determinants of healthCost, housing instability, transportation, food insecurity, or access barriers materially affect management.ModerateDecision regarding minor procedure with identified patient/procedure risk factorsUse only when the underlying CPT MDM criterion is genuinely met.HighDecision regarding hospitalization or escalation of carePsychiatric admission, emergency evaluation, or similarly intensive escalation.HighDrug therapy requiring intensive monitoring for toxicityMonitoring specifically intended to detect serious toxicity — e.g., lithium or clozapine when intensive toxicity monitoring is actually performed.HighOther qualifying high-risk management decisionFor example, a decision to de-escalate care because of poor prognosis, when applicable.

Risk level: Straightforward

6. Psychotherapy add-on details (optional)

Primary modalityTherapy focus

Distinct psychotherapy interventions

Suggested E/M and add-on

99212

Straightforward MDM

MDM rule: overall MDM is the highest level met by at least two of three elements (Problems: Straightforward, Data: Straightforward, Risk: Straightforward). Medical necessity, documentation, payer policy, and current CPT guidance control final billing.

Documentation builder

Patient-specific support

What usually does not count as psychotherapy

Medication education, side-effect review, adherence counseling, informed consent for medication, lab review, prescription changes, and routine treatment planning are generally part of the E/M service. Psychotherapy should be distinct, medically necessary, time-supported, and documented with its own therapeutic focus and interventions.

Quick reference

Service	Typical code selection logic
Office/outpatient E/M	99202–99205 new patient or 99212–99215 established, selected by MDM or qualifying E/M time.
Psychotherapy with E/M	+90833 (16–37 min), +90836 (38–52 min), +90838 (≥53 min) of distinct psychotherapy.
Psychotherapy without E/M	90832 (16–37 min), 90834 (38–52 min), 90837 (≥53 min).
Psychiatric diagnostic evaluation	90791 without medical services; 90792 with medical services.

Educational coding support only. This tool does not replace the current CPT codebook, AMA guidance, CMS or payer-specific policy, NCCI edits, certified coding review, or legal/compliance advice. CPT is a registered trademark of the American Medical Association.