What CPT codes are used for psychiatric medication management visits?

Use E/M codes 99212-99215 based on MDM complexity. Many psychiatrists use 99213 for routine follow-up; 99214 for medication changes or multiple medications. Psychiatric codes 90833 or 90836 can be added if psychotherapy is provided. Document complexity elements to support code selection. Time-based billing available if >50% of time spent counseling.

What symptom assessment documentation supports medication decisions?

Document: core depression symptoms (mood, anhedonia, sleep, appetite, energy, concentration, guilt, hopelessness, psychomotor changes, suicidal ideation), symptom severity using standardized tool (PHQ-9 score), functional impact, comparison to prior visit, and response category (full response, partial response, no response). Specific documentation supports medication decisions.

How should medication response be documented?

Document: percentage improvement from baseline, timeline of response (when improvement began), which symptoms improved vs persistent, current medication regimen with adherence, side effects (present, absent, tolerable), and whether current response warrants continuation or change. Include patient's subjective assessment of benefit.

What documentation supports medication change decisions?

Document: reason for change (inadequate response after adequate trial, intolerable side effects, patient preference, cost, drug interaction), duration of current trial at adequate dose, symptoms not responding, rationale for new medication choice, and expected benefit. For augmentation, document why adding rather than switching. This supports prior authorization.

How do I document suicide risk reassessment at follow-up visits?

Document: direct assessment of suicidal ideation (asked, not assumed), changes since last visit (new, improved, worsened), current plan/intent/means access if ideation present, risk level (low/moderate/high), protective factors, and safety plan status. Document even when negative ('Denies suicidal ideation'). Update risk assessment at every visit.

Depression Follow-up Template - Medication Management

Psychiatry — Depression Follow-up Visit Template

Psychiatry Psychiatry Updated: 11/7/2025

The Depression Follow-up Visit Template is designed for psychiatrists, psychiatric nurse practitioners, and primary care providers conducting follow-up visits for patients with depression. This focused template documents symptom response, medication effectiveness, side effects, functional improvement, and treatment plan adjustments. The template supports appropriate billing for medication management visits and includes sections for interval history since last visit, depression symptom assessment using standardized scales when appropriate, medication review with adherence and response, side effect monitoring, functional status assessment, suicide risk reassessment, treatment plan adjustments including medication changes, psychotherapy referral if indicated, patient education on depression and treatment, and follow-up scheduling. This template ensures comprehensive depression care, supports medication optimization, facilitates systematic symptom tracking, and improves patient outcomes through structured follow-up. Ideal for psychiatric practices, primary care practices managing depression, integrated behavioral health programs, and practices providing medication management for depression.

Visit Information

Visit type: Depression follow-up / Medication management
Date of last visit: [Date]
Days since medication start/change: [X] days

Interval History

Overall mood: Better / Same / Worse
Symptom changes: [Specific symptom changes]
Functional status: [Work, relationships, activities]
Life events: [Significant stressors or positive events]

Depression Symptom Assessment

Mood: [1-10 scale or descriptive]
Interest/pleasure: [Anhedonia assessment]
Sleep: [Hours, quality, early morning awakening]
Appetite: [Changes]
Energy: [Fatigue level]
Concentration: [Ability to focus]
Feelings of worthlessness/guilt: [Present / Absent]
Hopelessness: [Present / Absent]
PHQ-9 score: [If used]

Medication Review

Current medications: [List with dosages]
Adherence: Taking as prescribed / Missed doses / Barriers: [specify]
Perceived benefit: Helping / Not helping / Unclear
Side effects: None / [Specify]

Suicide Risk Assessment

Suicidal ideation: None / Passive / Active
Plan: None / [Specify if present]
Intent: None / [Specify if present]
Access to means: [If SI present]
Protective factors: [Reasons for living, support]
Risk level: Low / Moderate / High

Functional Assessment

Work/school: [Functioning level]
Relationships: [Social functioning]
Self-care: [ADLs]
Overall functioning: Improved / Stable / Declined

Physical Examination (Focused)

Vital signs: BP, HR, RR, Temp, Weight
General: Appearance, psychomotor activity
Mental status: [Brief MSE]

Assessment

1) Major Depressive Disorder, [Severity]

Response to treatment: Responding / Partial response / No response
Functional status: [Assessment]

2) [Other diagnoses as applicable]

Plan

1) Medication: Continue / Adjust dose / Change medication: [specify]

Rationale: [Reason for change]
Expected timeline: [When to expect improvement]

2) Psychotherapy: Continue / Refer: [specify]
3) Safety planning: [If indicated]
4) Patient education: [Depression, medication, warning signs]
5) Follow-up: Return in [timeframe] / Sooner if: [specify]

Patient Instructions

Treatment plan reviewed. Warning signs discussed. Patient verbalized understanding. Next appointment scheduled.