Policy / Article-010
Behavioral Health E/M Services Educational Guide
- Effective Date: 01/01/2026
- Reviewed/Revised Date: 03/23/2026
- Next Review Date: 03/23/2027
- Origination Date: 01/01/2026
-
Originated Department:
Correct Coding Integrity
Audience
Behavioral health E/M services involve the evaluation, diagnosis, and management of mental health conditions by a physician or qualified healthcare professional.
- CPT 2026 Professional Edition, AMA
- AMA CPT Assistant, ED guidance
- CMS Evaluation & Management Services Guide
- Official ICD-10-CM / CPT coding rules
Clinical Providers
✓ Psychiatrists
✓ Nurse Practitioners (Psych NPs)
✓ PAs
Coding & Billing Professionals
✓ Medical Coders
✓ Clinical Documentation Improvement (CDI) specialists
✓ Compliance and audit personnel
Overview
Behavioral health services may occur in or out of clinics, hospitals, residential treatment settings, and telehealth environments.
➔ Providers may select the E/M level based on MDM or total time on date of service.
➔ Providers commonly use standard E/M codes when performing psychiatric medical management.
➔ Behavioral health E/M services include:
- Psychiatric evaluation
- Medication management
- Assessment of psychiatric symptoms
- Treatment planning
- Coordination with behavioral health providers
- Risk assessment (suicide, self-harm, harm to others)
Documentation Essentials
Behavioral health E/M documentation should include:
✓ Chief Complaint – reason for the visit.
Example:
— Follow-up for major depressive disorder
— Medication management for bipolar disorder
✓ History of Present Illness – Include psychiatric symptom details:
- Mood changes
- Anxiety severity
- Sleep patterns
- Appetite changes
- Functional impact
✓ Mental Status Examination (MSE) – components include:
- Appearance
- Behavior
- Speech
- Mood and affect
- Thought process
- Thought content
- Cognition
- Insight and judgment
✓ Medical Decision Making – document:
- Diagnoses evaluated
- Medication management
- Risk assessments
- Treatment decisions
✓ Assessment and Plan — include:
- Diagnosis
- Medication adjustments
- Therapy recommendations
- Safety planning if necessary
- Follow-up care
Total time: 45 minutes
— including psychiatric evaluation,
medication management, psychotherapy counseling, and documentation.
✓ Select E/M Level using total time on date of service – Time may include:
- Patient evaluation
- Psychotherapy
- Medication management
- Review of records
- Care coordination
- Documentation
To support accurate coding, documentation should:
- Clearly describe psychiatric symptoms and diagnosis
- Document mental status examination findings
- Include medication management decision
- Describe risk assessment and safety planning
- Reflect medical necessity for treatment
Common Audit Triggers
- Missing mental status exam documentation
- Lack of medical necessity
- Psychotherapy add-on codes without documentation
- Insufficient risk assessment
- Missing time documentation
Office/Outpatient Visits
Pro Tip
Only include physician/qualified provider time spent directly managing the critical condition.
CPT Code
Patient Type
Typical Time on Date of Service
MDM Level
99202
New
15-29 min
Straightforward
99203
New
30-44 min
Low
99204
New
45-59 min
Moderate
99205
New
60-74 min
High
99212
Established
10-19 min
Straightforward
99213
Established
20-29 min
Low
99214
Established
30-39 min
Moderate
99215
Established
40-54 min
High
Psychiatric Add-On Code
Pro Tip
Use when psychotherapy is provided in addition to medication management.
CPT Code
Description
90833
Psychotherapy add-on (30 min) with E/M
90836
Psychotherapy add-on (45 min) with E/M
90838
Psychotherapy add-on (60 min) with E/M
Medical Decision Making (MDM)
Pro Tip
E/M level selection based on three MDM components.
Component
Behavioral Health Example
Low
Stable depression on medication
Moderate
Medication change due to side effects
High
Suicide risk evaluation or acute psychosis
Revision History
01/01/2026
Correct Coding Integrity
03/23/2026
Revised by Mountain Health CO-OP Policy Committee
Disclaimer
This document is for informational purposes only. It should not replace clinical judgment or provide medical advice. Coverage, benefits, and eligibility are determined by the member’s benefit plan. CPT codes and procedures included are for informational purposes only and do not guarantee reimbursement. © CPT Only – American Medical Association