How to choose time-based vs MDM for a psych E/M note

Office and outpatient E/M (99202-99215) can be selected by medical decision-making or by total time. You have to choose one basis and document that basis. If you also bill a psychotherapy add-on (90833, 90836, 90838), the choice disappears: CPT requires MDM for the E/M, and time spent on psychotherapy cannot feed the E/M. A note that never says which path you used is how a 99214 becomes a conversation with the MAC.

This sits next to reviewing mental health service codes. Here the problem is the fork in the note, not the CPT list.

Decide the basis before you pick a code

Ask one question: did I do psychotherapy I intend to bill as an add-on?

Yes: MDM for E/M. Write psychotherapy minutes in their own block. See how to document 90833.

No: you may use MDM or total time. Use whichever the documented visit actually supports. Do not pick the higher of the two after the fact without the documentation to match. That is the definition of a coding integrity problem.

Put a one-line statement in the note: “E/M selected by MDM” or “E/M selected by total time, 36 minutes.” Billers should not have to infer it.

When MDM is the cleaner path

MDM is usually cleaner for psychiatry because our visits are problem-heavy and the clock is messy (portal refills, waiting on a collateral call, a PHQ-9 on the tablet).

Document problems addressed, data reviewed (notes, PDMP, labs, independent historian), and risk of the management options. A lithium patient with a new NSAID, a climbing creatinine, and a dose decision is moderate or high MDM even if you were done in 22 minutes.

“Continue all meds” with two stable problems is low MDM. If that is the visit, a 99214 needs either more complexity than you wrote or a switch to time (if time is honestly long).

When total time is the cleaner path

Time wins when the medical work is not that complex but you honestly spent a long time: family meeting, lots of education, coordinating two specialists, a long safety discussion that is still E/M (not billed as psychotherapy).

Total time for office E/M is the clinician’s time on the date of the encounter: face-to-face plus non-face-to-face (chart review, documentation, ordering, calling the pharmacy) personally performed by the billing clinician. Staff rooming does not count. Psychotherapy minutes do not count if you are also billing an add-on (and in that case you cannot use time anyway).

Write the total minutes and a short list of what filled them. “36 minutes total: 10 chart review including last three lithium levels, 20 face-to-face, 6 documentation and pharmacy call.”

What to write on each path

MDM path:

E/M 99214 selected by MDM. Problems: bipolar I plus new eGFR decline. Data: lithium 0.9, BMP, PCP note. Risk: dose reduction vs relapse. Decision: reduce ER 1200 to 900 mg, repeat level in 5 days, nephrology referral.

Time path (no psychotherapy add-on):

E/M 99215 selected by total time. 58 minutes on the date of service. Face-to-face 40 (patient and sister), chart review 8, collateral with therapist 5, documentation 5. Counseling on taper schedule and sick-day lithium rules.

Do not mix. Do not add psychotherapy time into the 58. Do not select 99215 by time and also drop 90833 on the claim.

Prolonged services have their own rules and are not available in the usual way when a psychotherapy add-on is billed. If you think you need prolonged time, you probably should not be stacking 90833.

Questions people ask

Can I document both MDM and time “in case”? You can record both facts. You still pick one basis for the code. Ambiguous selection is what gets recoded.

Does a 20-minute visit with high-risk SI chart as 99215 on time? No. Twenty minutes is not 99215 on time. It might be 99214 or 99215 on MDM if the risk and problems are really there. Write the MDM.