Choosing the E/M level in psychiatry: 99213, 99214 and 99215

By Selam Koch, PMHNP-BC, founder of OneStep Scribe and practicing psychiatric nurse practitioner. Published August 2026.

Every established outpatient psychiatric visit gets a level. In the charts I review it is picked on instinct, running one direction: downward. The 2021 office and outpatient rules changed what the level rests on, and much psychiatric documentation never caught up.

This guide covers 99213, 99214 and 99215 for established patients. Below them, one self-limited or minor problem with straightforward decision making is a 99212, and 99211 needs no prescriber at all. If you pair the visit with a psychotherapy add-on, the E/M level still follows these rules, and the pairing mechanics live in billing 99214 with 90833.

CPT is a registered trademark of the American Medical Association; the criteria below are summarized in my own words, and the current manual is authoritative. Payers publish their own interpretations and audit standards, and those govern your claims. Level selection is the billing clinician's responsibility, so check your payer's policy and compliance resources before changing how you code.

The level is a conclusion, not a word count

You select an established visit two ways: by medical decision making, or by total time on the date of the encounter. History and examination no longer drive the level: you still document what is medically appropriate, but its volume does not move a 99213 to a 99214.

That change explains most psychiatric miscoding I see. Three pages with a full review of systems can still be a 99213; a tight note about one hard decision can be a 99214. Length is not the currency; the thinking is.

The three elements are how many problems you addressed and how complex they were, how much information you gathered from outside the interview, and how much harm your decision could expose the patient to.

Take the highest level that at least two of the three elements meet or exceed. Problems moderate plus risk moderate is a 99214 even if you reviewed nothing outside the room. One high element alone does not set the level: high with two lows is a 99213, and high with one moderate is a 99214.

Element one: problems addressed

A problem is addressed when you evaluate or manage it. Listing a diagnosis does not address it, and neither does noting a hypothyroidism diagnosis managed by primary care.

• Low, supports 99213: one stable chronic illness, a single uncomplicated acute problem, or two minor self-limited ones. Stable means at treatment goal, not unchanged since last visit. Moderate depression that is not improving is not stable.
• Moderate, supports 99214: a chronic illness that worsened, progressed or is producing side effects you are managing; two or more stable chronic illnesses; or a new problem you have not yet diagnosed with an uncertain course, the workhorse of psychiatric practice.
• High, supports 99215: chronic illness in severe exacerbation, or an illness that threatens life or bodily function. Acute suicidal ideation with intent or plan, mania with impaired judgment, psychosis with command hallucinations, severe restriction in an eating disorder, serotonin toxicity.

The undercoding error I see most often is "stable" in a note whose own body shows partial response, impairment or side effects being managed. If you are still titrating, the patient is not at goal.

Element two: data reviewed and analyzed

Data falls into three categories, plus one movable item.

• Category one: tests and documents. Ordering a unique test, reviewing the result of a unique test, reviewing prior notes from each unique external source.
• The independent historian. History from someone else because the patient cannot give an adequate account. In the AMA grid it has its own category at the low level and counts as a category one item at moderate and high. At the low level a historian plus one record review is not two items: the historian carries limited data alone or not at all.
• Category two: independent interpretation. You interpret a test another physician or qualified health professional performed and reported, without separately billing it. Reading the numbers on a lab you ordered is not independent interpretation: the category targets tests carrying a separate professional interpretation component, rare in psychiatry.
• Category three: discussion of management. Discussing management or a result with an external clinician or another appropriate source. External means outside your practice or group, or a different specialty within it; a same-specialty colleague in your group does not count. Appropriate source means a non-clinician involved in managing the patient, such as a case manager or probation officer, not family members or informal caregivers.

Limited data (99213) is two category one items, or an assessment that required an independent historian. Moderate data (99214) is three category one items, one independent interpretation, or one qualifying discussion. Extensive data (99215) is two of the three categories, and category one still needs three items when it is one of them, so extensive usually means three items plus an external discussion.

In practice: the prior prescriber's records and an outside therapist's summary are two unique sources. External applies here too, so the note by the therapist down the hall in your own practice is not countable. A lithium level, a TSH and a metabolic panel are three items, though ordering and later reviewing the same test counts once, and each needs a documented clinical reason. Order tests to answer a clinical question, never to reach a data threshold.

Collateral from a spouse, parent or group home staff when the patient cannot give an adequate history is the independent historian: document who, why it was needed, and what they said. Obtaining collateral and disclosing back to a collateral source are different acts, so record the authorization you relied on. State mental health confidentiality law, 42 CFR Part 2 and minor consent rules can be stricter than HIPAA. Collateral contact documentation covers the mechanics.

Element three: risk of management

Risk is what your management decision exposes the patient to, including the options you rejected. It is where psychiatric visits most often qualify at moderate, and where notes most often fail to show it.

Moderate risk is anchored by prescription drug management: starting, stopping, changing, titrating, tapering or cross-tapering. The AMA position is that a documented decision to continue a medication, with risks and benefits weighed on the page, also counts, but some payer auditors read that narrowly and want a change. If continuation is the only thing carrying risk, expect it to be tested, and a bare refill with no reasoning reads as low risk. Moderate also covers care constrained by social circumstances: cost, no transport to the lab, housing that makes a divided-dose regimen unworkable. Name the constraint and how it changed the plan.

High risk has two realistic anchors. The first is a decision about hospitalization or hospital-level care, counted when you genuinely consider it, admitted or not. Note the qualifier: intensifying outpatient treatment or shortening the interval is not by itself this element. Where you judge that a patient with acute suicidal ideation can be managed as an outpatient with a safety plan, means restriction and short-interval follow-up, that weighing is the hospitalization decision for coding. The coding rule never drives the disposition: document what you judged clinically appropriate, and record the crisis resources you gave, including 988. Suicide risk assessment documentation goes deeper.

The second anchor is drug therapy requiring intensive monitoring for toxicity, under three constraints: the drug must be capable of causing serious morbidity or death; the monitoring must be by laboratory, physiologic or imaging test, not by asking about symptoms; and long-term monitoring has to run at least quarterly. Clozapine with absolute neutrophil count monitoring qualifies. Short-term monitoring can, but it must target toxicity: repeating a PHQ-9 to see whether an antidepressant works is efficacy monitoring, as is a level drawn to confirm therapeutic range.

The three levels side by side

What the documentation has to show

The level is carried by the assessment and plan. A reader who never met the patient should be able to name the two elements that carried it. Both excerpts below are fictional.

Selecting the level by total time instead

You may select by the total time you personally spend on the date of the encounter: the face-to-face portion plus pre-visit record review, ordering, documenting and coordinating care. It excludes clinical staff time, time on a different day, and time already counted toward a separately reported service.

CPT removed the upper bounds in 2023, so these are thresholds, not ranges. Total time has to meet or exceed 20 minutes for 99213, 30 for 99214 and 40 for 99215. A 58 minute visit is a 99215 on time; there is no band it falls outside. Document the minutes and activities: "total time 34 minutes: pre-visit record review, the visit, medication ordering and documentation" is what the rule asks for, and a bare number is not. Either method is permitted, provided the documentation supports the one you rely on.

Prolonged service may only be added when you selected the E/M by total time and reached the top level, and it is reported in full 15 minute increments. The CPT add-on begins at 55 minutes for an established patient; Medicare's code begins higher, so confirm your payer's threshold.

Where prescribers get this wrong

In the charts I review, 99213 is the reflex level, because it feels safer. It is not neutral: a level pattern that does not track the record misdescribes the care delivered. Select the level the documentation supports, up or down. If you changed a medication and documented the weighing, you have moderate risk, and that is one element; check whether a second reaches moderate, usually the problem itself, before calling the visit a 99214. The mirror image is a template that carries last visit's assessment, plan and level forward when nothing was reconsidered. Tells: "continue current medications" while the level claims prescription drug management, a data line claiming record review with no source named, five diagnoses listed where one was addressed.

Frequently asked questions

Can a stable refill visit ever be a 99214?

Sometimes, but not by default. If the patient is at treatment goal on one medication and you made no decision beyond continuing it, you are at one stable chronic illness and low risk, which is a 99213. It becomes moderate when a second element rises: another chronic condition managed, a side effect you are addressing, or a data count reaching three category one items.

Does checking the prescription monitoring program count as data?

Treat it cautiously. A database query is not a test result, and is not a clinical note from a unique external source, so counting it as a data item is a stretch I would not rely on. It earns its keep on the risk axis instead: document what you found and how it changed your controlled substance decision.

Does a telehealth visit change how I pick the level?

The medical decision making rules carry over unchanged. What varies by payer is place of service, whether the encounter was audio and video or audio only, which modifier applies, and whether audio only is payable at all. Confirm current policy per payer.

Related guides

• Can you bill 99214 and 90833 together? Yes, and here is what each code has to prove
• The three psychotherapy add-on codes: choosing between 90833, 90836 and 90838
• Psychiatric progress note example: an annotated medication management follow-up
• 90832 vs 90834 vs 90837: choosing and documenting the psychotherapy time codes
• 90791 vs 90792: the real difference, with a complete psychiatric evaluation note example

This article is educational and reflects one clinician's understanding of coding rules at the time of writing. It is not legal, billing, or payer-specific advice, and it does not guarantee reimbursement or audit outcomes. Coding rules, payer policies, and state and federal laws change; always verify current requirements with your payers, coding resources, and compliance advisors, and consult your licensing board(s), current DEA guidance, and a healthcare attorney for licensure, consent, and controlled-substance questions. CPT is a registered trademark of the American Medical Association.