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Billing and coding

How to use E/M codes for evaluation and management services

Within behavioral health, billing and documentation for E/M codes can sometimes be confusing.

November 26, 2024

14 min read

Psychiatrists and nurse practitioners use E/M codes to code medical services provided outside of psychotherapy, like medication management. Ahead, find out how to use them for evaluation and management services.

What are E/M codes?

Evaluation and management (E/M) codes are a subset of CPT codes established by the American Medical Association (AMA) to represent services provided by physicians to assess and manage a patient’s health. E/M codes range from 99201 to 99499, and include care such as hospital observation services, emergency department services, and newborn care services, among others.

Unlike other CPT codes that designate time spent providing a service, specific procedures, or interventions, E/M codes reflect the physician’s effort to deploy various tasks — like history-taking, examination, communication, and medical decision-making — in a patient encounter in order to determine appropriate care.

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Using E/M codes for behavioral healthcare

Behavioral health psychiatric clinicians — such as psychiatrists and nurse practitioners — are most likely to use E/M codes ranging from 99201–99215, which represent “Office/other outpatient services” in the CPT codebook. 

As a psychiatrist or nurse practitioner, you might decide to use an E/M code instead of a code for psychotherapy (like 90837 or 90834) when you’re providing a service that is more medically oriented, or when the coordination or assessment of care is the primary focus.

Proper, compliant documentation is key when you’re billing E/M codes in behavioral health settings. Payers require detailed documentation illustrating why you provided a particular service for a patient’s diagnosis and treatment plan. Essential as it is for reimbursement, compliance can be a time-consuming process. Headway makes it easy to streamline your documentation and billing process so you can get paid on time, every time — without the added stress of figuring out if you’re using the right code or including pertinent details in your notes.

E/M coding tips for behavioral health

If you’re looking for an E/M code to bill your services as a psychiatrist or nurse practitioner, the appropriate code depends on, first:

New vs. established patient: There are separate codes for these two patient populations, based on whether the patient has received a service from the same physician or physician group practice under the same specialty within the previous 3 years. As a Headway provider, if you’re seeing a patient who is new to you but has seen a different Headway provider within the past three years, you would bill an established patient code rather than an intake code.

Then either:

  • Time: Total time spent towards care-related activities on the date of service. (Here’s what does and does not count.)
  • Medical decision-making (MDM): Though a patient may be subjectively complex or challenging, for billing purposes complexity is based on meeting or exceeding two of the three elements required for the level of medical decision-making represented by the established MDM level of the code: straightforward, low, moderate, or high. (See the MDM table here.)


E/M codes for office/other outpatient services:

The following codes apply to E/M services provided by a qualified medical professional:

New patient E/M codes:

  • 99202: Straightforward MDM, or minimum 15 minutes
  • 99203: Low MDM, or minimum 30 minutes
  • 99204: Moderate MDM, or minimum 45 minutes
  • 99205: High MDM, or minimum 60 minutes

Established patient E/M codes:

  • 99212: Straightforward MDM, or minimum 10 minutes
  • 99213: Low MDM, or minimum 20 minutes
  • 99214: Moderate MDM, or minimum 30 minutes
  • 99215: High MDM, or minimum 40 minutes

Psychotherapy add-on codes, for use with E/M codes:

If you’re both evaluating a patient’s health and providing talk therapy in the same encounter, you can use an E/M code along with a psychotherapy add-on code.

To ensure accurate documentation, it's essential to separately record the details of each service. For the E/M portion, focus on the medical evaluation and decision-making, and for the psychotherapy session, document the therapeutic techniques and interventions used. Both sections should stand alone in the session notes, reflecting that they are distinct components of the overall encounter.

Psychotherapy add-on codes:

  • 90833: Individual psychotherapy, 30 minutes (16-37 minutes face to face with the patient)
  • 90836: Individual psychotherapy, 45 minutes (38-52 minutes face to face with the patient)
  • 90838: Individual psychotherapy, 60 minutes (53 minutes or more face to face with the patient)

When incorporating psychotherapy add-on codes, your full documentation must include:

  • Total time spent in the session: This will include evaluation and management time plus psychotherapy time.
  • Time specifically spent conducting psychotherapy: Expressed as an exact length of time, not a range.

As well as:

  • Behaviors/symptoms: Specify the behaviors/symptoms being addressed with therapy.
  • Interventions: Identify the therapeutic techniques used and how they were applied. (It’s also helpful to include the patient's response to the interventions, which supports medical necessity.)
  • Plan/goal specific to therapy: Outline a measurable plan or goal specific to therapy.
  • Assessment of progress: Assess progress towards the stated plan or goal.

How do I know which method (MDM or total time) to use to select the level of visit?

  • If you’re coding an E/M code alone, you should select an E/M code using whichever method — time or MDM — best captures the nature of your service during the encounter.
  • If you’re coding an E/M code along with a psychotherapy add-on code, your use of an E/M code must be based on MDM. 

It’s important to include sufficient documentation to support the method you chose. For example: To code a brief encounter with a high-complexity patient, MDM might be a better reflection of the role you played as a medical provider. On the other hand, if you spent a length of time consulting a patient with a straightforward situation, it might be better to code based on total time.

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How to select E/M codes by total time

Documentation of work on the date of service is imperative when billing based on time. Be sure to justify why you spent a certain amount of time with the client within your documentation. 

The following activities count toward time when coding an E/M service: 

  • Preparing to see the patient on the date of service (e.g., review of tests)
  • Obtaining and/or reviewing the separately obtained history on the date of service
  • Performing a medically appropriate examination and/or evaluation on the date of service
  • Ordering medications, tests, and procedures on the date of service
  • Counseling and educating the patient/family/caregiver on the date of service
  • Referring and communicating with other health care professionals (when not reported separately) on the date of service
  • Documenting clinical information in the electronic or other health records
  • Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
  • Care coordination (not separately reported)


The following activities do not count toward time when coding an E/M service: 

  • Time spent on a previous or subsequent day
  • Activities performed by clinical staff (i.e., RNs, MAs)
  • When the E/M is warranted and separately identifiable, the time spent on separately reportable services (such as procedures, diagnostic tests, and professional interpretation) cannot be combined with the E/M time
  • Time spent on travel
  • Time spent on teaching that is general

How to select E/M codes by level of medical decision-making

Medical decision-making, or MDM, is a structured assessment that helps to reflect the complexity of work required by the provider in order to diagnose and treat the patient’s condition.

There are three elements of MDM, which can be graded on four distinct levels. 

3 MDM elements

MDM is based on three elements, as defined by the AMA:

  • Number and complexity of problems addressed at the encounter
  • Amount and/or complexity of data to be reviewed and analyzed (Note: As an additional layer to this assessment, this element contains another embedded evaluation of “category,” which specifies the proper combination of tests, orders, or documents that contribute to meeting the criteria for that level.)
  • Risk of complications and/or morbidity or mortality of patient management

4 MDM levels

E/M codes are graded on four levels of MDM, each with their own criteria for the three elements above:

  • Straightforward
  • Low
  • Moderate
  • High


In order to meet the criteria for a specific level of MDM, the criteria for two out of three of the elements must be met. For example, a patient who meets the criteria for a straightforward number and complexity of problems and carries a low level of risk of complications, the MDM would be considered straightforward.

Medical decision-making table for E/M codes

A full table of levels and elements of MDM is available below, reproduced from the AMA.

To better understand the terms in this chart, and how they apply to mental health care, consult the glossary below.

If you'd like more information about MDM documentation and best practices, check out our guide to 4-stop MDM documentation & leveling shortcuts.

Commonly used E/M coding terms

These key terms are likely to come up when you’re assessing E/M codes.

Definition of new patient vs. established or existing patient


New patient:

An individual who has not received any professional services, Evaluation and Management (E/M) service or other face-to-face service (e.g., surgical procedure) from the same physician or physician group practice and the same specialty within the previous 3 years.

Established patient / Existing patient:

An individual who has received professional services from the physician or another physician in the same group and the same specialty within the previous 3 years.


Definitions for terms related to: Complexity of problems


Self-limited minor problem:

A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status. 

Example: Bereavement 

Stable, chronic illness:

A problem with an expected duration of at least one year or until the death of the patient. Conditions are treated as chronic whether or not stage or severity changes.

Example: Uncontrolled diabetes and controlled diabetes are a single chronic condition. 

"Stable,” for the purposes of categorizing MDM, is defined by the specific treatment goals for an individual patient. A patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function. 

Example: Major Depressive Disorder, recurrent, in remission

Stable, acute illness:

A problem that is new or recent for which treatment has been initiated. The patient is improved and, while resolution may not be complete, is stable with respect to this condition. 

Example: Acute stress reaction

Acute, uncomplicated illness:

A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. A problem that is normally self limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness. 

Example: Adjustment disorder with depressed mood

Acute, complicated illness:

An illness that causes systemic symptoms and has a high risk of morbidity without treatment. 

Example: Anorexia with bradycardia or amenorrhea

Chronic illnesses with exacerbation, progression or side effects from treatment:

A chronic illness that is acutely worsening, poorly controlled, or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects. 

Example: Major Depressive Disorder, recurrent; moderate

Undiagnosed new problem with uncertain prognosis:

A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment. 

Example: Cognitive decline

Chronic illness with severe exacerbation, progression, or side-effects of treatment:

The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require escalation in level of care. 

Example: Major Depressive Disorder, recurrent, severe w/ significant functional decline

Acute or chronic illness or injury that poses a threat to life or bodily function:

An acute illness with systemic symptoms, an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without treatment. Some symptoms may represent a condition that is significantly probable and poses a potential threat to life or bodily function. These may be included in this category when the evaluation and treatment are consistent with this degree of potential severity.

Example: Depression with suicidal ideation and plan


Definitions for terms related to: Risk of complications, morbidity, or mortality of patient management


Social determinants of health:

Economic and social conditions that influence the health of people and communities. Examples of social determinants of health that contribute to medication non-adherence include food or housing insecurity.

Drug therapy requiring intensive monitoring for toxicity:

A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. The monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy. (Intensive monitoring is defined as obtaining lab results at an interval of not more than every 90 days.)

Examples: Initiation of Lithium, management of Clozapine

This document is intended for educational purposes only. It is designed to facilitate compliance with payer requirements and applicable law, but please note that the applicable laws and requirements vary from payer to payer and state to state. Please check with your legal counsel or state licensing board for specific requirements.

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This content is for general informational and educational purposes only and does not constitute clinical, legal, financial, or professional advice. All decisions should be made at the discretion of the individual or organization, in consultation with qualified clinical, legal, or other appropriate professionals.

© 2026 Therapymatch, Inc. dba Headway. All rights reserved. No part of this publication may be reproduced without permission.

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