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Psychiatric-mental health nurse practitioners (PMHNPs) are unique in that service provision can occur across the lifespan, and that scope of practice comprises an array of mental health services, including assessment, diagnosis, psychopharmacotherapy or medication management, and psychotherapy (Delaney, 2017). For this reason, PMHNPs are likely to use evaluation and management (E&M) coding, in addition to psychotherapy coding. With correct and appropriate coding, PMHNPs can not only maximize revenue, but increase efficiency and improve the quality of care delivery (Rosa et al., 2020). Given these factors and recent changes in 2021 for E&M coding through the Centers for Medicare & Medicaid Services (CMS) (Barton, 2021; CMS, 2020), the purpose of the current article is to provide an overview of coding for PMHNPs working in an outpatient setting.
E&M Coding for Outpatient Psychiatric Services
E&M coding is a medical coding process that is required for medical billing and reimbursement in the United States. Health care providers must use E&M coding to be reimbursed for their services through the CMS, in addition to private insurance companies. Through the coding process, patient encounters are translated into five-digit current procedural terminology (CPT) codes, which will be outlined below.
Previous E&M coding guidelines considered the following regarding billing: history, physical examination, and degree of medical complexity, or number of face-to-face minutes spent with the patient (American Academy of Professional Coders [AAPC], 2021; Bendix, 2014). Recent changes to E&M coding, as previously mentioned, apply to patients with Medicare or Medicaid. The CMS now considers only the number of minutes spent with patients or the degree of medical complexity when determining the correct code (Barton, 2021). However, private payers may still adhere to previous E&M coding guidelines; therefore, prudent PMHNPs will familiarize themselves with history and physical or mental status examination requirements to ensure appropriate reimbursement. Office or outpatient E&M codes range from 99202 to 99215 and can further be delineated based on whether the patient is new or established with the PMHNP (AAPC, 2021; CMS, 2020).
New Patients
Codes 99202 through 99205 refer to new outpatient visits. From the PMHNP perspective, most new outpatient visits will consist of a comprehensive psychiatric evaluation, and thus should be billed...