This course reviews the 2021 guidelines as they pertain to new and established psychiatry office patients. The new rules for coding based on time are discussed as well as the new methodology for calculating the medical decision-making. Using psychiatry clinical examples, we illustrate how to select the correct level of care for new and established office patients, then show how to document each encounter as expeditiously as possible. The conventions for using the initial psychiatric evaluation codes, psychotherapy codes and psychotherapy + E/M codes in the office setting are also reviewed.

This course uses the 1997 E/M guidelines to show how to find the "correct" level of care for any hospital encounter by focusing on the medical decision-making first, then illustrates how to perform and document the history and exam in a purpose-driven manner to make sure those elements are congruent with the E/M code being reported. The rules for coding for the initial psychiatric evaluation, psychotherapy and psychotherapy + E/M services in the hospital are also covered in detail.

This is a survey of the key components of history, physical exam and MDM using the 1997 E/M guidelines and focusing on the 1997 psychiatric specialty exam. The 1997 guidelines are still operative for all encounters other than new and established office patients, so a working knowledge of the rules is critical when it comes to streamlining your documentation and ensuring compliance.