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Telemedicine Statement
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Phone statement
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New Patient Visit
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Evaluation and Management Services
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Evaluation and Management Services with Psychotherapy
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Other visit type
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Visit type
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Reason for Visit
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Narrative
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Treatment Summary
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E/M Narrative
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Objective
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Psychotherapy Narrative
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Psychiatric History
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Psychiatric History
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Psychiatric History
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Assessment and Plan
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Diagnoses
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E/M Assessment
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Treatment Response and Adverse Effects
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Psychotherapy Assessment
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Psychotherapy Progress
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Plan
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E/M Plan
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Cognitive Testing
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Reason for Testing
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Was testing performed on the date of this encounter?
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Technician Time
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Psychotherapy Plan
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Follow-up
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How soon?
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How soon? (other)
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Medications Requiring Monitoring?
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Date of Last Monitoring, Results, Next Due
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Suicide and Violence Risk Statement
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Chronic risk of suicide
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Acute risk of suicide
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Chronic risk of violence
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Acute risk of violence
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Hospitalization Statement
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Hospitalization
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Billing
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99204
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99204 w/ Mod 25
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99205
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99205 w/ Mod 25
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99204+90838
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99204+90838 w/ Mod 25
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99205+90838
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99205+90838 w/ Mod 25
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99214
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99214 w/ Mod 25
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99215
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99215 w/ Mod 25
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99214
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99214+90833
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99214+90833 w/ Mod 25
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99214+90836
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99214+90836 w/ Mod 25
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99214+90838
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99214+90838 w/ Mod 25
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99215
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99215+90833
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99215+90833 w/ Mod 25
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99215+90836
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99215+90836 w/ Mod 25
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99215+90838
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99215+90838 w/ Mod 25
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Neuropsych Testing
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Neuropsych Testing Review
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TMS Treatment
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Telemedicine
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Telemedicine Visit
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Phone Visit
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Medical Decision Making
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Medical Decision Making
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Risk
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Risk
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Moderate
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Prescription Drug Management (Level 4)
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Significant limitations in diagnosis or treatment (Level 4)
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High
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Medication management requiring monitoring for toxicity (Level 5)
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High risk of harm to self or others (Level 5)
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Necessity for consideration of hospitalization (Level 5)
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Explanation
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Complexity
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Complexity
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Moderate
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Chronic illness with exacerbation‚ progression‚ or side effects of treatment (Level 4)
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Two or more stable‚ chronic illnesses (Level 4)
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New Problem (Level 4)
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High
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Chronic illness with severe exacerbation‚ progression‚ or side effects of treatment (Level 5)
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Acute or chronic illness posing significant threat to life or disability (Level 5)
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Explanation
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Data
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Amount and/or complexity of data reviewed
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Moderate
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High (2 or more of the following)
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3 Total Tests and/or Documents Reviewed
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Independent Interpretation of Tests
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Discussion of management or test interpretation with an external physician, other qualified healthcare provider, or appropriate
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Explanation
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Psychotherapy Time
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Start Time
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End Time
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Time Spent in Psychotherapy
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Time-Based Billing
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Time-based Billing
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Time
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Appointment Start Time
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Appointment Stop Time
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Total Face-to-face Time
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Total Non-face-to-face Time
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Total Time Spent on Encounter
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ROS/PMFSH
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ROS/PMFSH
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Review of Systems
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Review of Systems
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Physical Exam
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Physical Examination
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Physical Exam
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Mental Status Exam
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Mental Status Examination
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Appearance and Behavior
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Mood and affect
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SI, HI, AVH
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Insight and Judgment
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Other
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Medication Trials
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Antidepressants
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SSRIs
• • •
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SNRIs
• • •
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TCAs
• • •
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MAOIs
• • •
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SARIs
• • •
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TeCAs
• • •
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Serotonin Modulators
• • •
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Others
• • •
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Benzos
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Benzos
• • •
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Other Anxiety Meds
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Other Anxiety Meds
• • •
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Antipsychotics
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First Generation Antipsychotics
• • •
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Second Generation Antipsychotics
• • •
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Mood Stablizers
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Mood Stabilizers
• • •
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Stimulants
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Stimulants
• • •
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Non-stimulant ADHD medications
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Non-stimulant ADHD Medications
• • •
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Other Medications
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Other medications
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Past Medical, Social, and Family History
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Past Medical, Social, and Family History
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Past Medical History
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Psychiatric History
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Trauma History
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Substance Use History
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Relationship History
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Educational/Occupational History
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Current Living and Financial Situation
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Other Current Stressors
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Access to Firearms
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Family History
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Diagnostic Assessment
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Diagnostic Assessments
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Depression Assessment
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Depressive symptoms
• • •
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Anxiety Assessment
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Anxiety symptoms
• • •
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Psychosis Assessment
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Psychotic symptoms
• • •
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Trauma Assessment
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Trauma Assessment
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Criterion A Event
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Intrusion Symptoms
• • •
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Avoidance
• • •
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Negative alterations in cognitions and mood
• • •
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Alterations in arousal and activity (2 or more)
• • •
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Duration of symptoms
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Status
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ADHD Assessment
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ADHD Assessment
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Inattention (6 or more in kids, 5 or more in adults)
• • •
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Hyperactive (6 or more in children, 5 or more in adults)
• • •
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What situations are these symptoms present in?
• • •
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Were at least 3 of the above symptoms present before the age of 12?
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Do the symptoms interfere with or reduce the quality of social, academic, or occupational functioning?
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Obsolete
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Are symptoms better explained by another illness?
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ADHD assessment status
• • •
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Chief complaint (inactive)
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Telemedicine modality (obsolete)
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