BC Advantage - 2016 Issue 10

Auditing Same Day Psychotherapy and E/M Services: The Time Trap 

A problem-focused E/M service and the provision of psychotherapy on the same date of service are both separately payable, when medically necessary. A typical scenario is when the provider treats the patient's diagnoses by documenting the appropriate level of history, exam and medical decision making - such as a decision to change medications, or even keep medications the same - and also provides psychotherapy services for the patient. When auditing these services, here are some key things to remember. First, the E/M service is selected first based on the previously mentioned history, exam and medical decision-making. The...

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