E/M Weekly Tip: An E/M on the Same Day as Psychotherapy

Some patients receive evaluation and management (E/M) services on the same day as psychotherapy service by the same physician or other health care professional. To report both E/M and psychotherapy the two services must be significant and separately identifiable. Providers should reference the NCCI edits and rules to confirm CMS’ guidelines on appropriate billing of multiple services to the same patient on the same day.

The documentation must clearly reflect both services (E/M and psychotherapy) were rendered. The E/M service is selected based on the documentation requirements (history, examination, and medical decision making). The time spent performing the E/M service is not included in the psychotherapy time.

References:

• Medicare Part B Payments for Psychotherapy Services
• For more information, please visit the Medicare Claims Processing Manual, 100-04, Chapter 12 at CMS website (PDF, 1.1 MB)