This article outlines how to include add-on codes to your service codes in a progress note. For more information on setting up service codes for your practice, please refer to the following articles from our Knowledge Base:

• E&M Coding 
• Setup Service Code Short List and Billing Rates

An add-on code is used in conjunction with another service code to indicate multiple services. These include codes to indicate psychotherapy when done with medical evaluation and management, psychotherapy that involves interactive complexity, or for instances of crisis therapy when time extends beyond the first hour. For more information on add-on codes, see this resource from Psychiatry.org. 

From the work areas of your progress note or complete assessment, click   to enter a service code. 

If auto coding, your service code will populate in the first dropdown ('E&M Only). Use the third dropdown to select an 'Add on to Psychotherapy & Misc'. 

Click into the field to display available options:

Then click again to make a selection. This will populate the add-on code to your note. 

Alternately, you can pick from the 'OR - as a Code from List' dropdown on the right side of the Service Code pop-out to select additional service code types.

Alternately, when using E&M/auto coding, additional codes for "prolonged services" may automatically populate based on total time spent with the patient. For example:

If service codes are not populating charge amounts with or without modifiers, check the Billing Rates and Payer Rules tab in your individual setting, or click here for more information.

Click Done when finished. All service codes entered in the pop-out will be displayed within the work areas of the note.

Frequently Asked Questions

Q: How do I document extra time for psychotherapy to obtain a 90838 add on code?

Answer: Click into the Psychotherapy work area from Part 1 of the Prescriber Progress Note:

In the next screen - Today, Patient focused on - note feelings and/or problems as directed, then click Continue.

This next area is for therapeutic interventions. You can note the time spent on psychotherapy with the patient. For example, choosing the 53+ minutes option would assign the 90838 service code. 

This time represents only the time spent counseling the patient and family, and not the total time spent with the patient. The three time periods listed (16-37, 38-52, and 52+) are those recognized by the psychotherapy with E/M cpt codes. 

Click into the dropdown field to make a selection. When finished. Click Continue to return to the main work areas of your note.

The service code field should update automatically to include the 90838 add-on code: