Welcome to Headway's Resource Hub for psychiatrists and nurse practitioners! One of our goals is to take the guesswork out of accepting insurance, which includes setting our providers up for success should insurer audits come around.
Staying up to date on best practices around Evaluation and Management codes and Medical Decision Making help set you and your practice up for success. This article includes links to live sessions, Headway Academy courses, Help Center articles, and external trainings to help set you up for success.
Check out the resources below in order to:
- Gain confidence in billing and writing compliant notes
- Avoid errors and minimize legal and financial risks
- Maintain high standards of patient care and efficiency
Live offerings
We are offering two live opportunities for psychiatrists and nurse practitioners: 1) a webinar led by our medical director to cover best practices for Evaluation Management codes, Medical Decision Making, and more, and 2) office hours with a coding specialist to provide personalized guidance and answer your questions.
Sign up or watch using the links below:
- Webinar Recording (July 26, 2024) - E/M Coding for Psychiatrists and Psychiatric NPs
-
Coding and Documentation Group Q&A w/ Jessica CPC, CPMA – every Wednesday and Thursday (spots limited).
Billing & coding desktop reference
- Click here to view and download our one-page guide on E/M and Medical Decision Making.
- Click here to view and download our example 99214 + 90836 E/M with psychotherapy note.
Headway Academy courses
Headway Academy has courses designed to help you get started and be successful on Headway. Below are the courses most relevant to to Evaluation and Management codes and Medical Decision Making:
- Medical Decision Making [15 min]
- Medical Decision Making [60 min]
- Medical Necessity [10 min]
- Compliant Billing Practices Webinar [38 min]
- Compliant Evaluation and Management Billing and Coding Webinar [40 min]
Help Center articles
Our Help Center has resources to help you learn more about our product, how to use it, and other best practices. The articles below are related to Evaluation and Management codes and Medical Decision Making, recommended by our clinical team:
- Evaluation and Management (E/M) codes with add-ons
- Medical necessity
- Compliance deadlines for clinical documentation, and why it matters
External trainings
PESI is a leading provider of continuing education (CE) for mental health and healthcare professionals, partnering with Headway to offer CE credit. The courses below are related to Evaluation and Management codes and Medical Decision Making, recommended by our clinical team:
- [6 CEUs] "Mental Health Documentation & Medical Necessity: Simple, Clear Guidelines that Maintain Quality of Care and Protect Your Practice"
- [6 CEUs] "Mastering Differential Diagnosis with the DSM-5-TR™: A Symptom-Based Approach"
- [6 CEUs] "Suicide Assessment and Intervention: Assess Suicidal Ideation and Effectively Intervene in Crisis Situations with Confidence, Composure and Sensitivity"
- [12 CEUs] Certificate course for prescribers: "Advanced Psychopharmacology Online Course: Anxiety, Depression, Bipolar, & More!"
To learn more about accessing PESI, visit our article: Using Violet and PESI for continuing education with Headway.
Add-on psychotherapy codes
Add-on psychotherapy codes are specific codes used when a psychotherapy session is performed in conjunction with an Evaluation and Management (E/M) service by the same provider on the same day.
These codes ensure that both the medical and psychotherapeutic components of the visit are separately identified and billed appropriately. The add-on codes are used to document the time spent on psychotherapy services only, excluding any time devoted to the E/M service.
These codes can only be used with E/M codes (99202-99215).
| CPT code and description | Time range for billing |
|---|---|
| 90833: Individual psychotherapy | 16-37 minutes face to face with the client |
| 90836: Individual psychotherapy | 38-52 minutes face to face with the client |
| 90838: Individual psychotherapy | 53 minutes or more face to face with the client |
Documenting add-ons
Must be clearly separate from the E/M section of the progress note, and include:
- Identified issues addressed during psychotherapy
- Precise duration of time conducting psychotherapy
- Description of intervention / modalities utilized
- Treatment plan outlining goals for psychotherapy
- Assessment of progress towards goals
- Psychotherapy plan, care needs, and cadence
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