Coding Guidelines for Psychiatry at Rula

This guide covers key aspects of psychiatric coding, including:

1. When to use MDM vs. Time-Based E/M coding
2. MDM-Based Coding Explained: Problems, Data, and Risk
3. Time-Based Coding Explained
4. Criteria for selecting and supporting psychotherapy add-on codes
5. How to code intake visits for transfer or established patients

If you’re looking for the full list of MDM coding criteria, please visit the APA-Quick-Guide here.

When to use MDM vs. Time-Based E/M coding

CPT codes for outpatient E/M services (e.g., 99202–99215) can be selected based on either Total Time spent on the date of service or the complexity of Medical Decision Making (MDM).

Note, when psychotherapy is provided and billed with an E/M code, the visit must be coded based on MDM only—time-based coding is not allowed in these cases.

The table below explains how each method works, when it's typically used, and how code levels are determined:

MDM-Based Coding Explained: Problems, Data, and Risk

For a full list of MDM coding criteria, please visit the APA-Quick-Guide here.

When using Medical Decision Making (MDM) to code a visit, you'll assess three key elements, each of which is assigned a complexity level (straightforward, low, moderate, or high). The three elements are:

1. Number and complexity of problems addressed
2. Amount and/or complexity of data reviewed and analyzed (Note: Telepsychiatry rarely involves sufficient data to meet this requirement, as it typically includes elements such as independent interpretation of lab results, X-rays, etc)
3. Risk of complications and/or morbidity/mortality of patient management

To select the correct E/M code (e.g., 99214), you must meet or exceed the requirements for at least two of the three elements at that level of complexity. Here is the complexity table mapped to each code:

Here's what each element of MDM means in practice:

1. Number & Complexity of Problems Addressed

This refers to the type and severity of the patient’s current problems, as well as how many are being actively managed. More complex or unstable conditions (e.g., suicidal ideation, worsening bipolar disorder) support higher code levels.

• Low Complexity: One stable condition (e.g., MDD in remission)
• Moderate Complexity: One new dx with uncertain prognosis, An existing dx with worsening symptoms/side effects or two or more stable diagnosis (e.g., anxiety + insomnia)
• High Complexity: Serious or life-threatening conditions/severe exacerbation of a chronic condition (e.g., psychosis, active suicidal ideation with plan and intent)

2. Amount and/or Complexity of Data to be Reviewed and Analyzed

This includes any information you review or obtain during the visit to make clinical decisions. It can come from tests, external records, MIC scores, other clinicians, or patient/caregiver input.

• Limited Data: Review of 1 test result, ordering a test or one outside note review (must meet 1 of 2 categories in the section)
• Moderate Data: Review of multiple sources, discussion with another provider, independent, ordering multiple tests, interpretation of results (must meet 1 of 3 categories in the section)
• Extensive Data: Extensive record review, multiple external discussions,  independent test interpretation, discussion of test interpretation with external provider (must meet 2 out of 3 categories in the section)

3. Risk of Complications and/or Morbidity/Mortality of Patient Management

This reflects the overall risk involved in the management of the patient. Risks are increased when the patient presents with high acuity diagnoses, medications are started or adjusted and/or if there are immediate safety concerns such as acute suicidal ideation/psychosis necessitating hospitalization/higher level of care.  

• Low Risk: Supportive care, no meds, no safety concerns
• Moderate Risk: Prescribing or adjusting medications, presence of social determinants of health impacting treatment (food and housing instability)
• High Risk: Patient requires hospitalization due to severe symptoms, high-risk medication initiation requiring intensive monitoring (Lithium, Clozapine) 

Time-Based Coding Explained

Time-based coding allows you to select an E/M code based on the total time spent on the day of the visit, including face-to-face time and non-face-to-face activities such as reviewing records, documenting, and coordinating care. This method is often used for longer visits where complexity is lower but time is significant, such as initial intakes or consultations.

The table below outlines the time requirements for each code:

Criteria for the use of psychotherapy add-on codes

Important: Rula does not permit the use of therapy add-on codes when billed in conjunction with 99205 or 99215.

Transfer Patient Intake Sessions

If a patient has completed an initial psychiatric evaluation (CPT 99205) with any Rula psychiatric medication management provider OR with the same provider at a different location within the past 3 years:

• The patient is considered an ESTABLISHED patient.
• The provider must bill using the appropriate established patient billing code (e.g., 99215 time-based).
• The provider may utilize the initial evaluation or follow-up charting template to collect all needed information
• The provider is unable to utilize a new patient E/M code (eg, 99205) with a 3-year timeframe.

Updated April 17, 2026 19:26