E/M Coding in Mental Health

Q:

My question pertains to the new E/M guidelines in the setting of mental health.  Under Amount and/or Complexity of Data for codes 99205 and 99215, it states that 2 of the 3 categories must be met to count Data as Extensive.  For services provided in mental health we find we are only meeting 1 category.  Does this mean we will always have to down code to 99214?

A:

The short answer is no, if the two other sections (or what the AMA titles as “Elements of MDM”) to support 99205/99215.  The three sections/elements of MDM are:

  1. Number and Complexity of Problems Addressed
  2. Amount and/or Complexity of Data to be Reviewed and Analyzed
  3. Risk of Complications and/or Morbidity or Mortality of Patient Management

The overall MDM must meet or exceed 2 of the 3 sections/elements.  If the patient’s condition supports high in Number and Complexity of Problems Addressed and high in Risk, then those two elements of MDM will support 99205 or 99215 even though the patient’s encounter does not support extensive in Data. 

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