The 2021+ office E/M rules in one paragraph
Since January 2021, office and outpatient E/M codes (99202–99215) are selected by either medical decision-making (MDM) or total time on the date of the encounter. History and exam must be “medically appropriate” but no longer count toward the level, which is why the old bullet-counting of ROS and exam elements is gone. For established patients: 99212 is straightforward MDM, 99213 low, 99214 moderate, 99215 high. MDM has three elements — number and complexity of problems addressed, amount and complexity of data reviewed and analyzed, and risk of complications of patient management — and the level is the one met or exceeded by two of the three. This guide covers the psychiatric application; the definitions are the AMA CPT E/M guidelines, and payers audit against them.
MDM: problems, data and risk, with psychiatric examples
Psychiatry usually reaches 99214 on problems plus risk. The data element is the one that most often stays at “limited,” and because only two of three elements are needed, that is fine. The table gives the CPT definitions in the left column and what they look like in an outpatient psychiatric practice on the right.
| Level | Problems addressed | Data reviewed and analyzed | Risk of patient management |
|---|---|---|---|
| Low 99213 | One stable chronic illness (at treatment goal — e.g., MDD in remission on unchanged sertraline); or one acute, uncomplicated problem (e.g., adjustment disorder after a move); or two or more self-limited problems | Limited: any two of — review of external notes from a unique source, review of a unique test result, ordering a unique test; or an assessment requiring an independent historian | Low risk from testing or treatment: e.g., OTC melatonin, sleep-hygiene counseling, referral to psychotherapy with no prescription decision |
| Moderate 99214 | Two or more stable chronic illnesses (e.g., MDD and GAD, both at goal); or one chronic illness with exacerbation, progression or side effects of treatment (e.g., MDD not at goal, PHQ-9 rising; akathisia on aripiprazole); or one undiagnosed new problem with uncertain prognosis (e.g., new-onset panic attacks vs hyperthyroidism); or one acute illness with systemic symptoms | Moderate: one of three categories — (1) any three of: external notes per unique source, unique test reviewed, unique test ordered, independent historian; (2) independent interpretation of a test performed by another clinician (e.g., personally reading the ECG tracing for QTc, not separately billed); (3) discussion of management with an external physician or QHP (e.g., a call with the PCP about a lithium–NSAID interaction) | Prescription drug management — starting, stopping, adjusting, or deciding to continue a prescription with a documented assessment; or diagnosis or treatment significantly limited by social determinants of health (e.g., cannot afford the medication, no transport to labs) |
| High 99215 | One chronic illness with severe exacerbation or progression (e.g., MDD with active SI, acute mania); or an acute or chronic illness posing a threat to life or bodily function (e.g., SI with plan and intent, anorexia nervosa with bradycardia, suspected lithium toxicity) | Extensive: two of the three categories above | Drug therapy requiring intensive monitoring for toxicity (e.g., clozapine ANC monitoring, lithium level monitoring — assessed by lab, at least quarterly); decision regarding hospitalization or escalation of care (including a documented decision not to admit); parenteral controlled substances |
Three definitions carry most of the weight. “Stable” in CPT means at treatment goal: a patient whose depression is unchanged but still symptomatic is not stable, and that problem counts as chronic with progression — moderate. “Prescription drug management” includes the decision to continue a medication, but only when the note shows the assessment behind it (dose, response, side effects, decision); a bare “continue meds” will not survive an audit. “Addressed” means you evaluated or managed the problem at this visit; a diagnosis on the problem list that was not discussed does not count.
The rule that follows from the two-of-three logic is the one clinicians miss most often: one stable chronic illness plus prescription drug management is a 99213, not a 99214. Problems are low, risk is moderate, data is minimal — only two elements reach “low,” so low is the level. To reach 99214 with a single diagnosis, that diagnosis must be not at goal, progressing or producing side effects.
Time-based coding
Time is total clinician time on the date of the encounter, face-to-face and non-face-to-face. The CPT 2024 revision restated the thresholds as minimums that must be met or exceeded; in practice they match the original 2021 ranges.
| Code | Total time on the date of service | Original 2021 range |
|---|---|---|
| 99212 | 10 minutes or more | 10–19 |
| 99213 | 20 minutes or more | 20–29 |
| 99214 | 30 minutes or more | 30–39 |
| 99215 | 40 minutes or more | 40–54 |
| Prolonged | CPT 99417 for each additional 15 minutes beyond the 99215 threshold (from 55 minutes); Medicare uses G2212 with a later start (69 minutes for established patients) — check the payer | — |
Counts toward time: preparing to see the patient (reviewing prior notes and results), obtaining or reviewing separately obtained history, the evaluation itself, counseling and educating the patient or family, ordering medications and tests, referring and communicating with other professionals when not separately reported, documenting in the EHR, independently interpreting results and communicating them, and care coordination when not separately reported. Does not count: minutes reported under another code (psychotherapy add-on time, 96127 scoring), clinical staff time, travel, teaching, and any work done on a different date — the note you finish tomorrow morning does not count toward today’s visit.
When you use time, write the total and what it included: “Total time on the date of service 34 minutes, including record review, the visit, medication reconciliation and documentation.” A number alone is a claim; the list is documentation.
Psychotherapy add-ons with E/M: 90833, 90836, 90838
Prescribing clinicians who provide psychotherapy in the same visit as medication management report an E/M code plus a psychotherapy add-on. The add-ons are time-based; the E/M is not.
| Add-on | Descriptor | Psychotherapy time required |
|---|---|---|
| 90833 | Psychotherapy, 30 minutes, with E/M | 16–37 minutes |
| 90836 | Psychotherapy, 45 minutes, with E/M | 38–52 minutes |
| 90838 | Psychotherapy, 60 minutes, with E/M | 53 minutes or more |
Four rules govern the combination:
- The E/M must be selected by MDM. CPT does not allow time to select the E/M level when psychotherapy is reported in the same encounter, because the psychotherapy minutes already have a code.
- Psychotherapy time is documented separately and excludes the E/M work (history, MSE, medication decisions). The note should show the minutes, the modality, the interventions and the patient’s response — see the progress note example for the block.
- Both services must be medically necessary and separately identifiable. Supportive conversation during a medication review is part of the E/M; psychotherapy is a distinct, planned intervention with a treatment goal.
- The add-ons attach to E/M codes only. They cannot be reported with 90791 or 90792 (see the 90791 vs 90792 guide), and they replace — not accompany — standalone psychotherapy codes 90832–90837 for that visit.
Documentation that supports each level
Three synthetic MDM paragraphs. Each names the elements; none asserts a level without evidence.
99213 — one stable chronic illness, prescription continued:
99214 — two chronic illnesses, one not at goal:
99215 — severe exacerbation with a hospitalization decision:
Why the third example reads this way: the decision about hospitalization is what creates high risk, even though the decision was not to admit. The note records the alternatives considered, who agreed, and the mitigation — which is the documentation a reviewer needs to accept high-risk MDM and, separately, the documentation a defense attorney needs.
Downcoding and upcoding pitfalls
Downcoding (the more common problem in psychiatry):
- Billing 99213 for every medication-management visit because “it only took fifteen minutes.” MDM does not depend on the clock.
- Calling a symptomatic patient “stable” because nothing changed. Not at goal is chronic with progression — moderate.
- Not documenting the assessment behind a continued prescription, so prescription drug management cannot be counted.
- Forgetting that a parent, spouse or group-home staff member giving history is an independent historian, and that reviewing outside records counts per unique source.
- Not writing total time on visits where time would have supported a higher level than MDM (a 42-minute visit with moderate MDM is a 99215 by time, if no psychotherapy add-on is billed).
Upcoding (what audits target):
- 99214 for a single stable chronic illness with a refill — the two-of-three rule makes it a 99213.
- Selecting the E/M by time while also billing 90833, or counting the psychotherapy minutes inside the E/M time.
- Counting problems that were not addressed at the visit because they appear on the problem list.
- 99215 justified by “complex patient” without a high-risk decision, a threat to life or function, or extensive data.
- Including staff time, or documentation completed on a later date, in total time.
- Copy-forward MDM paragraphs that describe last month’s medication change.
Worked example
Take the follow-up visit in the progress note template: an established patient with MDD (partial response, not at goal) and GAD (improving), sertraline continued at 100 mg after assessment of response and a sexual side effect, PHQ-9 and GAD-7 reviewed, and 20 minutes of CBT-based psychotherapy documented separately.
- Problems: two chronic illnesses, one not at goal → moderate.
- Data: two rating scales reviewed, no external records, no independent historian → limited.
- Risk: prescription drug management with a documented decision → moderate.
- Result: moderate MDM (two of three) → 99214, selected by MDM because a psychotherapy add-on is reported. Psychotherapy of 20 minutes → 90833.
Now remove the psychotherapy. The same visit, with a documented total time of 36 minutes on the date of service, is a 99214 by either path. At 42 minutes it becomes a 99215 by time even though MDM is moderate — and the note should say which path selected the code. Add the psychotherapy back, and time is off the table again.
An MDM block you can paste at the end of a note:
How many RVUs is 99214?
On the Medicare Physician Fee Schedule for CY2025, the work RVUs for established office visits are 99212: 0.70 · 99213: 1.30 · 99214: 1.92 · 99215: 2.80; these values have not changed since the 2021 office E/M revaluation. Moving a correctly documented visit from 99213 to 99214 is therefore a 48 percent increase in work RVUs for the same encounter. Payment is total RVUs (work plus practice expense plus malpractice) multiplied by the geographic adjustment and the year’s conversion factor, all of which change annually — use the current CMS fee schedule lookup for your locality rather than any dollar figure quoted online. For psychotherapy add-on values, see the current schedule.
Psynopsis writes the problems addressed with their status, the medication decisions with their rationale, and a separate psychotherapy block into every draft, so the MDM elements are in the note before you choose the code. It surfaces the elements; the level is your decision. See the feature overview, or the workflows for psychiatrists and PMHNPs.
Psynopsis writes the problems addressed with their status, the data reviewed, and the medication decisions in the language the MDM table uses — and keeps psychotherapy time separate — so the level you choose is supported by the note you sign. It surfaces the elements; you select the code.
See it on your next noteEducational content for licensed clinicians about documentation practice. It is not clinical advice and does not replace clinical judgment or your organization’s documentation standards. Examples are synthetic and contain no patient information.