Codes and Documentation for Evaluation and Management Services

EVALUATION AND MANAGEMENT CODES MOST LIKELY TO BE USED BY PSYCHIATRISTS AND OTHER APPROPRIATELY LICENSED MENTAL HEALTH PROFESSIONALS 

It is vital to read the explanatory notes in the CPT manual for an accurate understanding of when each of these codes should be used.

Note: For each of the following codes it is noted that: “Counseling and/or coordination of care with other providers or agencies is provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.” As stated earlier, when this counseling and coordination of care accounts for more than 50% of the time spent, the typical time given in the code descriptor may be used for selecting the appropriate code rather than the other factors

Office or Other Outpatient Services

NEW PATIENT

99201—The three following components are required:

• Problem-focused history

• Problem-focused examination

• Medical decision making that is straightforward 

Presenting problem(s): Self-limited or minor Typical time: 10 minutes face-to-face with patient and/or family

99202—The three following components are required:

• Expanded problem-focused history

• Expanded problem-focused examination 

• Medical decision making that is straightforward

Presenting problem(s): Low to moderate severity Typical time: 20 minutes face-to-face with patient and/or family

99203—The three following components are required:

• Detailed history 

• Detailed examination

• Medical decision making of low complexity

Presenting problem(s): Moderate severity 

Typical time: 30 minutes face-to-face with patient and/or family

99204—The three following components are required:

• Comprehensive history 

• Comprehensive examination 

• Medical decision making of moderate complexity

Presenting problem(s): Moderate to high severity 

Typical time: 45 minutes face-to-face with patient and/or family

99205—The three following components are required:

• Comprehensive history

• Comprehensive examination

• Medical decision making of high complexity

Presenting problem(s): Moderate to high severity 

Typical time: 60 minutes face-to-face with patient and/or family