A patient with COPD and HTN comes in for continuing psychotherapy, which lasted 30 minutes. The psychiatrist documented the psychotherapy as well as reporting the patient's COPD and HTN medications with problem-focused history, problem-focused exam, and low medical decision making. How is this coded?

Question

Quizplus · Accepted Answer

The psychotherapy is coded as 90833 (30 minutes of individual psychotherapy). The documentation of the COPD and HTN medications, problem-focused history, and exam can be coded as 99212 (a level 2 outpatient visit). The low medical decision making supports the use of 99212 instead of a higher level E/M code. Combining the two codes, the correct choice is 99212, 90833.

A Patient with COPD and HTN Comes in for Continuing