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CPT DOCUMENTATION REQUIREMENTS FOR E/M CODE 99214
WITH AN ADD-ON PSYCHOTHERAPY SERVICE
When an E/M office visit is provided together with an add-on psychotherapy code (90833, 90836 or 90838), the E/M code must be documented based on elements, not time.
First, a chief complaint must be included in each note.
In addition, each 99214 note must include documentation of two of the following three elements: a detailed history, a detailed examination and medical decision making of moderate complexity. However, since typical psychiatric documentation will include an interval history and examination for each visit with an established patient, there is no need to document the third element, complexity, for a 99214 visit provided both history and examination are documented. In addition to the chief complaint, the treatment record must include the proper level of documentation of History of Present Illness (HPI), Review of Systems (ROS), Past, Family and/or Social History (PFSH) and the Psychiatric Examination.
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CPT Coding and Documentation Update and Refresher Webinar
Presented by: Seth P. Stein, Esq.
Tuesday - September 23, 2014 - 8:00pm
The webinar will review the newly revised psychotherapy template that now includes identification of type of psychotherapy. The webinar will also review the new combination codes and the documentation requirements for those psychiatrists who are not familiar with the new codes or missed last year's webinar. Finally, the webinar will offer suggestions regarding substantiation of medical necessity and dealing with adults. The webinar will include an opportunity to submit questions.
Click to view
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NYSPA Templates for Progress Notes
You have two options when choosing to use a template - the template version of the form can be printed and completed by hand or, if you prefer to enter your information electronically into the form, you can download the fill-in version of the form. After entering the information into the designated spaces on the form, you can print the form to be included in the patient’s chart and/or save the completed form directly to your computer.
Instructions for completing the forms, sample templates, Word versions of the templates and fill-in forms, can be downloaded below.
By downloading any documentation forms, templates or instructions from the NYSPA website, you agree that such documents are copywrited material and may only be used by the NYSPA member for the member's personal use in the member's medical practice and any documents downloaded may not be sold, transferred or used for any other commercial or business purpose.
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CPT Coding Update Webinar
Presenter: Seth P. Stein, Esq.
Webinar Date: December 17, 2013
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CPT Coding Update Webinar
Presenter: Seth P. Stein, Esq.
Webinar Date: May 13, 2013
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2013 CPT Changes
NYSPA has been actively working to educate our members about major current procedural terminology (CPT) changes that went into effect on January 1, 2013.
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