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Practice Management

We've compiled several resources to assist with your Practice Management needs. Should you have additional questions, the APA has a Practice Management Helpline that puts you in contact with staff in the APA’s Office of Healthcare Systems and Financing who will provide assistance with problems you are encountering in your practice. Call 800-343-4671.

CPT Code Changes Begin January 1, 2021

Beginning in 2021, there will be  changes in the way psychiatrists bill and document office/outpatient evaluation and management (E/M) services, including simplified documentation and a new “prolonged” code, 99217. 

As of January 1, codes for office/outpatient medical evaluation and management (E/M) care can be selected on the basis of the complexity of the medical decision making (MDM) or on the basis of the total time on the date of the service related to the patient encounter, not just face-to-face time. 

For psychiatrists who provide E/M services along with psychotherapy, the appropriate E/M code must be determined by the level of the MDM, as newly defined. Time cannot be used to determine E/M when adding on psychotherapy. 

The revised MDM guidelines are outlined in the Medical Decision Making table of the “Quick Guide to 2021 Office/Outpatient E/M Services (99202-99215) Coding Changes,” which includes psychiatric specific examples as illustrations. This guide also includes cheat sheet for the new time ranges (to be used when billing for time). 

When billing outpatient E/M on the basis of time, psychiatrists may now use the total time on the date of the service related to the patient encounter, not just the face-to-face time. This includes:

  • Preparing to see the patient (e.g., review of test, records)
  • Obtaining and/or reviewing separately obtained history
  • Performing a medically necessary exam and/or evaluation
  • Counseling and educating the patient/family/caregiver
  • Ordering medications, tests, or procedures
  • Referring and communicating with other healthcare professionals (when not reported separately)
  • Documenting clinical information in the electronic or paper health record
  • Independently interpreting results of tests/labs and communication of results to the family or caregiver
  • Care coordination (when not reported separately)

A new prolonged service code (99417) was created for use when outpatient E/M services exceed each 15 minutes beyond the highest level E/M code (99205, 99215).

The level of MDM should be driven by the nature of the presenting problem on the date of the encounter. Time is not a factor when code selection is done on the basis of MDM.

A collection of resources for  the 2021 changes to the CPT Office/Outpatient Evaluation and Management codes, including the aforementioned “Quick Guide” and a recent webinar recording, are now available on the APA website. 

Remember, if you ever have a specific question about how to code for a particular patient encounter, you can send an email to APA’s Office of Healthcare Systems and Financing coding network: [email protected].

How To Sign Up for the Controlled Substance Reporting System

  1. To sign up visit: https://nccsrs.hidinc.com/ncsignup.html, where a login window will be displayed
  2. Enter newacct in the User Name field
  3. Enter welcome in the Password field
  4. Follow the instructions on the screen to complete your registration. Be sure to select “Master Account” and have your DEA and Medical Board number handy when you go to sign up. 
  5. After you have completed the above, you will be emailed your username and password to access the site.

If you have any questions, please call the CSRS staff at 919-733-1765 or email [email protected]

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