Billing & Coding
7 articles
When 90785 interactive complexity applies
90785 is an add-on code for interactive complexity, never billed alone. Four qualifying situations, codes it attaches to, what the...
90791 vs 90792, plus a full eval note
90791 vs 90792 hinges on medical services, which only 90792 includes. A PMHNP covers who can bill it, a complete intake note, and what...
90832 vs 90834 vs 90837: picking by time
90832, 90834, and 90837 time thresholds side by side, how to document psychotherapy time in the note, and why 90837 draws extra payer...
96127 billing for brief screeners
96127 is reported per instrument, not per visit: how to count units for the PHQ-9, GAD-7, or ASRS, what the note must show, and payer...
Billing 99214 with 90833 in one visit
You can bill 99214 with 90833 on one visit. Level the E/M by medical decision making, meet the 16-minute psychotherapy threshold, and...
90833 vs 90836 vs 90838: picking the tier
90833 covers 16 to 37 minutes, 90836 38 to 52, 90838 53 or more. How to count add-on time, choose the tier, and document the split...
99213 vs 99214 vs 99215: choosing the E/M level
Choose 99213, 99214 or 99215 with the two-of-three MDM rule: what counts as data, why prescribing sets risk at moderate, and the 2023...
Note Examples
11 articles
CPT 90833 note example, audit-ready
A full 90833 example note, annotated section by section: what the E/M carries, what the psychotherapy add-on must show, and what a...
DAP, BIRP and GIRP notes, side by side
One therapy session written three ways, as a DAP note, a BIRP note and a GIRP note, with what each format captures and how to choose...
A full psychiatric progress note, annotated
Psychiatric progress note example for a medication management visit, shown in full and annotated to flag the details that carry the...
Psychiatric SOAP note, section by section
A psychiatric SOAP note example written out in full from an ADHD stimulant follow-up, with what subjective, objective, assessment, and...
Treatment plan goals you can measure
Why vague treatment plan goals fail, one vague goal rewritten into a specific measurable target, and the goal language payers accept...
Documenting lifestyle counseling in psych notes
How to document lifestyle counseling in a psychiatric note: sleep, exercise, caffeine and alcohol, in language that supports medical...
Documenting medication informed consent
Medication informed consent in a psychiatric note: the four elements to chart, the wording to use for high-risk medications, and when...
What a telehealth psych note must include
POS 10 means the patient was at home, POS 02 means anywhere else. Modifier 95, consent, and location: the telehealth psychiatry...
Documenting collateral contacts
Collateral contacts belong in the chart with the authorization behind them: how to record who called, what was said, what you...
Documenting controlled substance prescribing
What the chart must show when you prescribe stimulants or benzodiazepines: baseline justification, PDMP findings, monitoring cadence,...
The psychiatric discharge and transfer summary
What a psychiatric discharge or transfer summary must contain: course of care, current meds and doses, dated risk status, refill...
Assessment
10 articles
Documenting an adult ADHD evaluation
Adult ADHD evaluation, step by step: childhood onset, impairment across settings, the differential, rating scales, and controlled...
Bipolar II vs borderline: the differential
Bipolar II vs borderline personality disorder: hypomania lasting days versus mood shifts in hours, the history to take, and how to...
Choosing psychiatric rating scales
PHQ-9, GAD-7, ASRS, MDQ, and AUDIT-C compared: what each scale is validated to measure, how to score it, how often to repeat it, and...
Mental status exam: two complete examples
Mental status exam documentation: every component, how to capture each one in a routine visit, normal and abnormal write-ups, and five...
MSE vocabulary bank
Mental status exam descriptors by domain: exact wording for appearance, speech, affect, thought process, cognition, and judgment, plus...
PHQ-9 and GAD-7: documenting the scores
Where the PHQ-9 and GAD-7 score belongs in the note, how to state severity without implying a diagnosis, what item 9 requires of you,...
Psychiatric intake: the questions to ask
Psychiatric intake questions for a 60-minute evaluation: history of present illness, risk, substances, medical and family history, and...
Sleep assessment in the psychiatric visit
Sort onset from maintenance insomnia, spot the apnea red flags that need referral, and document a sleep assessment that supports MDM...
Substance use screening, documented
Substance use screening documentation: what a psychiatric note needs around an AUDIT-C or DAST-10 score, how the result feeds MDM, and...
Suicide risk assessment documentation
Suicide risk assessment documentation that survives chart review: which risk and protective factors to record, stratification wording,...
Practice & Compliance
7 articles
Prior authorization in psychiatry
Prior authorization in psychiatry: which chart details payers actually require, what to say when the peer-to-peer call comes, and how...
Measurement-based care in psychiatry
Measurement-based care in psychiatry, sized for a 20-minute visit: which scales to repeat, how often, and how to document a score that...
What an AI scribe changes for psychiatrists
Med management visits, risk documentation, and the calls that still need you: what an AI scribe for psychiatrists changes in the note,...
Do therapists actually need an AI scribe?
What an AI scribe does for therapists writing 90834 and 90837 session notes, the confidentiality questions to ask first, and where it...
What HIPAA and the BAA require of an AI scribe
HIPAA requires a signed BAA before an AI scribe touches PHI. What that agreement must cover, plus encryption, storage, retention...
How to get patient consent for an AI scribe
Patient consent for an AI scribe: a fifteen-second script to say before you record, the line that documents it in the note, and what...
No-show and late cancellation documentation
What to document when a patient misses a psychiatric visit: the entry, tiered outreach, the controlled substance call, and why a...