Billing and Coding Guide - 2020 Health Behavior Assessment and Intervention
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
For additional information, contact:
APA Office of Health Care Finance
OHCF@apa.org
2020 Health Behavior Assessment and Intervention
Billing and Coding Guide
EXECUTIVE SUMMARY SECTIONS
• Coverage Indications, Limitations, and Medical Necessity:
Effective January 1, 2020, Current Procedural Terminology
This section provides descriptions of the assessment and treat-
(CPT®) codes 96150–96155 were deleted and a new code set
ment services; specifics on determining medical necessity
was implemented to report Health Behavior Assessment and
(pages 3-5); and limitations of coverage (pages 5-6).
Intervention (HBAI) services. APA Services, Inc. developed this
guide to provide an explanation of the extensive changes as well • Coding Information: This section contains a complete listing
as describe the structure, function, and utilization of the new and description of the new health behavior CPT® codes effec-
code set established through APA’s collaborative work with tive January 1, 2020 (pages 6-7).
the American Medical Association (AMA) and the Centers for • General Information: This section describes the documen-
Medicare and Medicaid Services (CMS). tation elements that are typically necessary to include in the
The information contained in each of the guide’s sections is patient record to support use of the codes as well as coding
provided to the right. APA encourages payers and providers to guidelines and instruction for proper reporting (pages 7-9).
utilize the guide to navigate the new landscape of health behav- • Utilization Guidelines: This section provides instructions to
ior assessment and intervention services, and to become famil- assess coverage provisions and appropriateness of services
iar with the coding guidelines and payment policies associated provided to a patient(s) and/or their family. The instructions
with these procedures. are intended to improve quality and efficiency of care, reduce
Please direct any questions about this guide to APA’s Office unnecessary and/or inappropriate services, and manage the
of Health Care Finance at OHCF@apa.org and the appropriate cost of health care benefits (page 9).
APA Services expert will contact you. Additional APA Services’ • Sources of Information: This section lists the scientific
resources are publicly available on APA’s website (https:// evidence and educational resources to support the contents
www.apaservices.org/practice/reimbursement/health-codes/ of this guide (pages 9-11).
health-behavior).
© 2019 APA Services Inc. CPT Copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.For additional information, contact:
APA Office of Health Care Finance
OHCF@apa.org
2020 Health Behavior Assessment and Intervention
Billing and Coding Guide
The initial development of health behavior services began in 1998 spinal cord injury (Russell et al., 2016), amputations (Highsmith
to satisfy the need for psychological assessment and intervention et al., 2016) and bariatrics (Sogg et al., 2016).
services for patients who presented with a known or established As clinician and medical condition specification continued to
medical illness. These services were developed to assess how develop, health behavior services were used with increasing
the medical illness was affecting the patient’s physical health frequency in outpatient settings for both primary and specialty
and well-being and address any identified impact by modifying care, a finding that is supported by Medicare claims data (2002–
the associated psychological, behavioral, emotional, cognitive, 2017). For example, in 2002, only 9% of the claims for the Health
and social factors (CPT Assistant, March 2002). As a result, a and Behavior Assessment service (CPT code 96150) were in
CPT codes 96150–96155 were implemented in 2002 and health General Outpatient compared to 24% in 2017. The same time
behavior service began to be more widely provided. period saw a 20% increase in the use of the Health and Behav-
Over the past two decades, there has been a significant increase ior Individual Treatment service (CPT code 96152) in General
in the development and adaptation of evidence-based techniques Outpatient and 10% increase in the use of this code in Physician
to address psychological factors impacting physical illness (Roditi Offices (AMA, 2019). The higher frequency of use of the codes
et al., 2011; Richards et al., 2018; Wysocki et al., 2006; Wilfley et in outpatient settings can be attributed to the increased focus
al., 2018). Treatment strategies have evolved from the general on integrating behavioral health services into both primary and
application of behavioral expertise to physical health conditions specialty care settings (APA, 2016; SAMSA-HRSA, 2018).
to the application of specific psychological principles in the global The population of patients with chronic noncommunicable
treatment of physical health conditions. Interventions commonly diseases like the ones listed above has also grown since the code
used include (but are not limited to) cognitive restructuring, oper- set was initially developed resulting in a significant increase in
ant behavior therapy and contingency management, stimulus complexity and cost of care (The US Burden of Disease Collab-
control, graded activation and behavioral activation, coping skills orators, 2018). For example, it is estimated that just 5% of
training, problem solving training, functional and structural family patients account for 50% of health care costs. The National
therapy, family communication training, relaxation skills training, Academy of Medicine identified four core groups of high cost
and motivational interviewing. These changes have resulted in patients: 1. children with severe disabilities; 2. adults with signif-
greater specialization in training, as well as the development of icant chronic illness (two or more complex conditions, and one
treatment guidelines for psychologists providing these services in complex plus one to five noncomplex conditions); 3. frail elderly;
both the primary care (McDaniel et al., 2014) and specialty care and 4. disabled patients under 65. Within these high-cost groups,
settings for chronic non-communicable diseases such as cardio- there is a subgroup of high needs patients defined as complex
vascular disease (Bosworth et al., 2018), obesity (APA, 2018), medical high cost patients. These individuals typically have func-
pain (Wandner et al., 2019), diabetes (ADA, 2018), traumatic tional limitations and their circumstances often require behav-
brain injury (Ponsford et al., 2016), stroke (Hildebrand, 2015), ioral services (Hayes et al., 2016; Long et al., 2017; Nahin, 2015).
© 2019 APA Services Inc. CPT Copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.Effective and efficient treatment of these high-cost and high- Health behavior intervention includes promotion of functional
need patients necessitates health behavior assessment to eval- improvement, minimization of psychological or psychosocial
uate the behavioral and psychological variables contributing to barriers to recovery, and management of and improved coping
poor health care monitoring, adherence, and health-promoting with medical conditions. These services emphasize active
behaviors to determine specific behavioral interventions and patient/family engagement and involvement (AMA, 2020).
other service needs.
Health Behavior Assessment or Re-Assessment
As the types and severity of these conditions have also evolved, Health behavior assessment and re-assessment (CPT code
there is a greater need for inclusion of health behavior services 96156) consist of assessing multiple domains and their degree
in patient treatment plans. In fact, the six risk factors contribut- of impact, which can include but are not limited to:
ing to over a third of all health care costs: tobacco use, poor diet,
• Relevant medical history
substance abuse, high Body Mass Index, high systolic blood pres-
sure, and high resting glucose levels (The US Burden of Disease • Adjustment to the medical illness or injury
Collaborators, 2018) all have clear behavioral determinants that • Psychological and environmental factors affecting manage-
can be effectively addressed by HBAI services. ment of the medical condition
Given how health behavior services have dramatically changed • Health beliefs, perception, and outlook
over time, especially in areas of provider technique and knowl-
• Understanding of treatment plan, benefits and risks of
edge, patient population, and the health care settings in which
procedures
they are offered, APA worked in collaboration with the AMA and
CMS to establish the 2020 Health Behavior Assessment and • Health care decision-making skills
Intervention (HBAI) code set. This new/revised family of codes • Coping strategies, patient strengths
more accurately reflect current clinical practice, providing greater
• Motivation and self-efficacy beliefs
focus on psychological and/or psychosocial factors in health as
well as the increased role these services have in interdisciplinary • Treatment adherence and expectations
care, particularly in primary, specialty care, post-acute, rehabil- • Daily activities, level of behavioral activation, and functional
itation, and skilled nursing facility settings. impairment
• Sleep, diet, physical activity, and other health risk behaviors
COVERAGE INDICATIONS, LIMITATIONS, AND
MEDICAL NECESSITY • Mental health and substance use (including tobacco and alco-
hol use)—current and past
Health Behavior Assessment and Intervention (HBAI) services
are used to identify and address the psychological, behavioral, • Social support, family and interpersonal relations
emotional, cognitive, and interpersonal factors important to • Academic and vocational histories
the assessment, treatment, or management of physical health
• Mood
problems. The patient’s primary diagnosis is physical in nature
and the focus of the assessment and intervention is on factors • Quality of life
complicating medical conditions and treatments. These codes
describe assessments and interventions to improve the patient’s Components of Health Behavior Assessment and/or
health and well-being by utilizing psychological and/or psycho- Re-Assessment
Three required elements that must be performed and docu-
social interventions by a qualified health provider designed to
mented in order to report CPT code 96156:
ameliorate specific disease-related problems.
i. Health-focused clinical interview: Depending on the nature
Health behavior assessment includes evaluation of the patient’s
of the referral question, the qualified health care professional
responses to disease, illness or injury, outlook, coping strategies,
(QHP) conducts the face-to-face health-focused clinical inter-
motivation, and adherence to medical treatment. Assessment is
view with the patient that may assess multiple domains as
conducted through health focused clinical interviews, observa-
outlined above. Collateral interviews are conducted as appro-
tion, and clinical decision making.
priate. When it precedes a health behavior intervention, the
© 2019 APA Services Inc. CPT Copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. 2clinical assessment would determine the type(s) of interven- Re-Assessment
tion that would best benefit the patient. In addition to meeting all the criteria stated above, medical neces-
ii. Behavioral observations: The QHP evaluates how the patient sity for re-assessment must be further established through docu-
is responding throughout the health-focused clinical interview mentation of one of the following:
through direct behavioral observation. There will be variabil- • Change in the mental or medical status warranting
ity across patients depending on a wide variety of factors re-evaluation;
including patient complexity, comorbidities, severity of medi-
• Specific concern from the primary medical provider or member
cal condition(s), and other factors that drive the clinical deci-
of medical team;
sion-making process.
• Need for re-assessment as part of the standard of care;
iii. Clinical decision making: The QHP integrates information
learned prior to the interview (record review, discussions • Change in providers; or
with other health care providers) with information gained • At least a 6-month period of time has elapsed since the last
during the health-focused clinical interview and behavior assessment.
observations to formulate the case conceptualization/clini-
Health behavior assessment or re-assessment is considered
cal impressions, established or suspected medical diagnoses,
medically necessary for one or more of the following indications,
any additional diagnoses determined by the QHP, and treat-
where there is a need to:
ment recommendations.
1. Assess psychological and/or behavioral factors that impact
Medical Necessity: Health Behavior Assessment or the management of a patient’s acute or chronic medical condi-
Re-Assessment tion (e.g., assessment of stress and its impact on diabetes
The Health Behavioral Assessment or Re-Assessment service management); or
may be considered reasonable and necessary for the patient who
2. Assess patient’s responses to disease, illness or injury, outlook
meets all the following criteria:
(e.g. health beliefs and attitudes), coping strategies, motiva-
• The patient has an established or suspected underlying phys- tion, and adherence to medical treatment; or
ical illness or injury and the purpose of the assessment or
3. Assess behavioral and contextual factors that impact disease
re-assessment is not primarily for the diagnosis or treatment
management in scenarios that include, but are not limited to:
of mental illness;
a. pre-surgical evaluation to identify psychological factors
• There are indications that psychological, behavioral, and/or
that may potentially affect or complicate the outcome of
psychosocial factors may be affecting the treatment or medi-
surgical procedures and/or aftercare (e.g., spinal surgery,
cal management of an illness or an injury;
bariatric surgery, implantable therapies, organ transplant);
• The patient is alert, oriented, and has the capacity to under-
b. assessment of emotional/personality factors impacting
stand and to respond meaningfully during the face-to-face
physical disease management and ability to comply with
encounter;
and/or benefit from medical interventions;
• The patient has an established or suspected underlying phys-
c. assessment of psychosocial and/or environmental factors
ical illness or injury needing a health behavior evaluation and/
that can impact a patient’s ability to comply with and/or
or intervention to successfully manage their physical illness
benefit from medical interventions; or
and activities of daily living.
4. Assess psychological barriers and strengths to aid in treatment
• The patient can be referred from a medical or mental health
planning, including but not limited to:
care provider, or self-referred to seek assistance in addressing
the role of psychological and/or behavioral factors affecting a. the selection of treatment options when several evidence-
an underlying physical health condition. based approaches may be indicated;
b. determining treatment prognosis and outcomes;
c. identifying reasons for poor response to medical treat-
ment; or
© 2019 APA Services Inc. CPT Copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. 35. Assess and monitor psychological factors and impact on medi- • Psychoeducation related to the psychological, behavioral, and/
cal condition and management over time (repeated assess- or psychosocial aspects of the patient’s illness or presenting
ments); or problem
6. Assess health related risk behaviors (e.g., sleep, diet, physical • Stimulus control
activity, tobacco use) and their impact on the medical condi- • Functional and structural family treatment
tion and management.
• Communication skills training
Health Behavior Intervention • Mindfulness techniques
Intervention services may be provided to:
• An individual (and is billed with CPT codes 96158, +96159); Medical Necessity: Health Behavior Intervention
Services
• A group of two or more patients (and is billed with CPT codes The health behavioral intervention services (CPT codes
96164, +96165 for each individual patient in the group); 96158/+96159, 96164/+96165, 96167/+96168, 96170/+96171)
• A family, with the patient present (and is billed with CPT codes may be considered reasonable and necessary for the patient who
96167, +96168); or meets all of the following criteria:
• A family, or without the patient present (and is billed with CPT • The patient has an underlying physical illness or injury
codes 96170, +96171) • Specific psychological intervention(s) and patient outcome
› Note: APA firmly believes that Health Behavior Family Intervention with-
goal(s) have been clearly identified and documented
out the patient present (96170/+96171) should be a reimbursable service
as it benefits the patient’s medical treatment and management; however,
• Psychological intervention is necessary to address:
as coverage varies, providers should check with their insurance carrier
for verification of coverage.
› Non-adherence with the medical treatment plan, or
Family intervention services, whether the patient is or is not pres- › The psychological and/or psychosocial factors associated
ent, involves face-to-face interaction with “family representa- with a newly diagnosed physical illness, or an exacerbation
tive(s)” (see definition in the Addendum B) (CMS, 2018). of an established physical illness, when such factors affect:
Health behavior intervention includes promotion of functional – symptom management and expression
improvement, minimization of psychological or psychosocial – health-promoting behaviors
barriers to recovery, and management of and improved coping – health-related risk-taking behaviors
with medical conditions. These services emphasize active – overall adjustment to medical illness.
patient/family engagement and involvement.
• There are indications that psychological, behavioral, and/or
Evidence-based health behavior interventions address psycho- psychosocial factors may be affecting the treatment or medi-
logical/behavioral factors that can be influencing a person’s cal management of an illness or an injury
medical condition and consist of various types of treatment inter-
• The patient is alert, oriented and has the capacity to understand
ventions, including but not limited to:
and to respond meaningfully during the intervention service
• Motivational interviewing
In addition to the criteria above, family intervention with patient
• Problem solving training present (CPT codes 96167/+96168) and without patient pres-
• Coping skills training ent (CPT codes 96170/+96171) is considered reasonable and
necessary for the patient who meets all of the following criteria:
• Relaxation techniques and skills training
• The “family representative” (see definition in the Addendum
• Cognitive restructuring
B) directly participates in the overall care of the patient, and
• Emotional awareness and management
• The psychological intervention with the patient and family
• Operant behavior therapy and contingency management is necessary to address psychological and/or psychosocial
• Graded activation, behavioral activation, and pacing factors that affect adherence with the plan of care, symptom
techniques management, health-promoting behaviors, health-related
© 2019 APA Services Inc. CPT Copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. 4risk-taking behaviors, and overall adjustment to medical illness. meaningfully during the face-to-face encounter for reasons
such as, but not limited to:
Health behavior intervention services are considered
› Cognitive status that indicates inability to actively partici-
medically necessary when one or more of the
pate and benefit from services;
following needs are present:
1. Modify and manage psychological and behavioral factors › Severe dementia that has produced a severe enough
that are impacting the management of a patient’s acute or cognitive defect for the psychological intervention to be
chronic medical condition (e.g., improve stress management ineffective;
to improve diabetes management); or › Severe or profound intellectual disability;
2. Modify and/or improve a patient’s cognitive or emotional › Persistent inability to engage in meaningful interpersonal
responses to disease, illness or injury, outlook, coping strate- interactions including inability to respond to cues and
gies, motivation, and adherence to medical treatment through directions.
the on-going maintenance or improvements resulting from
evidence-based treatments; or The following would not be considered medically
3. Modify and/or improve psychological and/or behavioral necessary if provided as the primary health behavior
factors that impact disease management in scenarios that intervention service:
• Updating or educating the family about the patient’s condition
include but are not limited to:
• Educating family members who do not meet the definition
a. Psychological factors affecting or complicating the
of “family representative” (see definition in the Addendum B),
outcome of surgical procedures and/or aftercare (e.g.,
and other members of the treatment team (e.g., health aides,
spinal surgery, bariatric surgery, implantable therapies);
nurses, physical or occupational therapists, home health aides,
b. The emotional/personality impacts on physical disease personal care attendants, and co-workers) about the patient’s
management and/or the ability to comply with and benefit care plan.
from medical interventions; or
• Treatment-planning with staff
4. Modify and/or improve a patient’s adherence to medical treat-
• Mediating between family members or providing family
ment and/or health risk-related behaviors; or
psychotherapy
5. Modify and/or improve a patient’s engagement in self-man-
• Education that does not include the psychological, behav-
agement and participation in treatment; or
ioral, and/or psychosocial aspects of the patient’s illness or
6. Modify and/or improve a patient’s understanding of the medi- presenting problem
cal condition, its treatment, and the psychological, behavioral,
• Delivering Medical Nutrition Therapy (i.e., CPT codes 97802;
emotional, cognitive, or social factors related to the prevention,
Medical nutrition therapy; initial assessment and intervention,
treatment or management of the medical condition.
individual, face-to-face with the patient, each 15 minutes, 97803;
Limitations of Coverage Medical nutrition therapy; re-assessment and intervention, indi-
Health behavior assessment and intervention services will not be vidual, face-to-face with the patient, each 15 minutes, and 97804;
considered reasonable and necessary for the patient with any of Medical nutrition therapy; group (2 or more individual(s)), each
or all the following criteria: 30 minutes)
• Does not have a suspected or established underlying physical • Retraining cognition due to dementia or memory enhancement
illness or injury; or training (i.e., CPT codes 97129; Therapeutic interventions that
focus on cognitive function (e.g., attention, memory, reasoning,
• For whom there is no indication that psychological and/or
executive function, problem solving, and/or pragmatic function-
psychosocial factors may be significantly affecting the treat-
ing) and compensatory strategies to manage the performance of
ment, or medical management of an illness or injury (i.e.,
an activity (e.g., managing time or schedules, initiating, organiz-
screening medical patient for psychological problems); or
ing, and sequencing tasks), direct (one-on-one) patient contact;
• Does not have the capacity to understand and to respond initial 15 minutes and 97130; Therapeutic interventions that focus
© 2019 APA Services Inc. CPT Copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. 5on cognitive function (e.g., attention, memory, reasoning, exec- • All medical necessity criteria for health behavioral interven-
utive function, problem solving, and/or pragmatic functioning) tion services are not met (see medical necessity criteria in the
and compensatory strategies to manage the performance of an Section 1.E); and/or
activity (e.g., managing time or schedules, initiating, organizing, • The family representative does not directly participate in the
and sequencing tasks), direct (one-on-one) patient contact; each plan of care; and/or
additional 15 minutes)
• The family representative is not present.
• Provision of support services, not requiring the skills of an indi-
Health Behavior Family Intervention without the patient present
vidual with health psychology training.
(96170/+96171) is not considered a covered service under Medi-
• Provide personal, social, recreational, and general support care and by some private insurers and state Medicaid programs.
services.*
Note: APA firmly believes that Health Behavior Family Intervention without the
*While personal, social, recreational, and general support services may be valu-
patient present (96170/+96171) should be a reimbursable service as it benefits
able adjuncts to care, they are not considered psychological health behavior
the patient’s medical treatment and management; however, as coverage varies,
interventions. Example of these services are:
providers should check with their insurance carrier for verification of coverage.
• Stress management for support staff
Please note that this document does not provide a guarantee that
• Replacement for expected nursing home staff functions
HBAI services are reimbursable under a particular plan, payer,
• Recreational services, including dance, play, or art
medical, or behavioral health benefit; therefore, it is highly recom-
• Music appreciation
mended that providers contact each plan regarding coverage
• Craft skill training
decisions.
• Cooking classes
• Individual or group social activities
• General conversation
CODING INFORMATION
• Consciousness raising
CPT Codes and Descriptors for HBAI Services
• Vocational or religious advice
96156; Health behavior assessment or re-assessment (i.e., health-fo-
• General educational activities
cused clinical interview, behavioral observation, clinical decision
• Visits for loneliness relief
making)
• Sensory stimulation
96158; Health behavior intervention, individual face-to-face; initial
• Games, such as bingo
30 minutes
• Projects, such as shopping outings, even when used to reduce a dysphoric
state
+ 96159; Health behavior intervention, individual face-to-face; each
• Teaching grooming skills
additional 15 minutes (List separately in addition to code for primary
• Grooming services
service)
• Monitoring activities of daily living
(Use 96159 in conjunction with 96158)
• Teaching the patient simple self-care
• Teaching the patient to follow simple directives 96164; Health behavior intervention, group (two or more patients),
• Wheeling the patient around the facility face-to-face; initial 30 minutes
• Orienting the patient to name, date, and place
+ 96165; Health behavior intervention, group (two or more patients),
• In-vivo exercise programs, even when designed to reduce a dysphoric state
face-to-face; each additional 15 minutes (List separately in addition
• Case management services including but not limited to planning activities
to code for primary service)
of daily living, arranging care or excursions, or resolving insurance problems
• Activities principally for diversion (Use 96165 in conjunction with 96164)
• Planning for milieu modifications
96167; Health behavior intervention, family (with the patient present),
• Contributions to patient care plans
face-to-face; initial 30 minutes
• Maintenance of behavioral logs
+ 96168; Health behavior intervention, family (with the patient pres-
Health Behavior Family Intervention services with the patient ent), face-to-face; each additional 15 minutes (List separately in
present (96167/+96168) and without the patient present addition to code for primary service)
(96170/+96171) will not be considered reasonable and neces-
(Use 96168 in conjunction with 96167)
sary for the patient if:
© 2019 APA Services Inc. CPT Copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. 696170; Health behavior intervention, family (without the patient • Relevant medical history
present), face-to-face initial 30 minutes • Relevant psychological and/or psychosocial history (when
+ 96171; Health behavior intervention, family (without the patient appropriate)
present), face-to-face; each additional 15 minutes (List separately in • Sources of information (e.g., patient interview, record review,
addition to code for primary service) behavioral observations)
(Use 96171 in conjunction with 96170) • Services performed
+ Indicates an Add-On Code to be reported with primary service/base code
• Clinical decision making (see description in the Section 1.B.iii)
Note: APA firmly believes that Health Behavior Family Intervention without the
i. Impressions
patient present (96170/+96171) should be a reimbursable service as it benefits
the patient’s medical treatment and management; however, as coverage varies,
ii. Diagnosis
providers should check with their insurance carrier for verification of coverage.
iii. Treatment planning and recommendations
ICD-10-CM Codes that Support Medical Necessity
Documentation should be legible, signed, include the QHP’s
for HBAI Services
credentials, and maintained in the patient’s medical record.
Due to the wide range of physical health diagnoses a patient
could have to necessitate Health Behavior Assessment and/or Medical records need not be submitted with the claim; however,
Intervention services, there is not a list of “approved” codes that all coverage criteria must be clearly documented, and the medi-
support medical necessity. Instead, a list of ICD-10-CM codes cal record, (e.g., nursing home record, doctor’s orders, progress
that are known not to support medical necessity when reported notes, office records, and nursing notes), must be available to
as the primary diagnosis is provided in a separate addendum. the payer upon request.
(See Addendum C for a list of non-covered primary diagnosis codes.) Because of the impact on the medical management of the
• ICD-10-CM diagnosis code(s) reflecting the physical condi- patient’s disease, documentation should typically show evidence
tion(s) being treated must be documented on the claim form and/or attempts of communicating and coordination with the
(Box 21 A of the CMS-1500 form) as the primary diagnosis. patient’s medical provider responsible for the medical manage-
ment of the physical illness that the health behavior assessment
• However, in the case where a patient also has a mental health
and/or intervention was meant to address.
diagnosis, it should be reported as a secondary condition using
traditional mental health diagnosis codes. Documentation in the medical record must include:
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E) • For the Assessment, evidence to support that the assessment
ICD Incl. is reasonable and necessary (see medical necessity criteria in
A. Primary dx B. 2* Dx C. 3* Dx D. 4* Dx the Section 1.C), and must include at a minimum the following
elements:
E. F. G. H.
I. J. K. L.
› Documented health-focused clinical interview,
› Diagnosis of physical illness,
• ICD-10-CM codes must always be coded to the highest level
of specificity. › Clear rationale for why assessment or re-assessment is
required,
GENERAL INFORMATION › Behavioral observations, including mental status and ability
to understand or respond meaningfully,
Documentation Requirements
The patient’s medical record should contain documentation › Clinical decision-making related to the formulation of the
that supports the medical necessity for health behavior services case conceptualization/clinical impressions, and treat-
performed, including the following information: ment recommendations (e.g. goals and expected duration
of specific psychological intervention(s), if recommended).
• Referral question and suspected or established medical
diagnosis • For Re-assessment, evidence to support that the re-assess-
ment is reasonable and necessary must be documented in
© 2019 APA Services Inc. CPT Copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. 7detailed progress notes. In addition to meeting all the criteria Coding Guidance
for assessment (see medical necessity criteria in the Section 1.C), If the health behavior assessment or re-assessment (CPT code
these detailed progress notes must include at least one of the 96156) is unable to be completed during a single encounter, the
following elements: date of service indicated on the claim should be the date on which
the interview was finalized.
› Change in mental or medical status warranting re-evaluation;
It is typical for psychological testing and health behavior assess-
› Specific concern from the primary medical provider or
ment and/or intervention services to be provided to the same
member of medical team for why re-assessment is required;
patient; often on the same date of service. Any psychological
or need for re-assessment as part of the standard of care; or
testing performed in addition to the health assessment or re-as-
a change in providers; or at least a 6-month period of time
sessment should be additionally reported, based on the type of
has elapsed since the last assessment;
testing performed (AMA, 2004).
› Clear indication of the precipitating event that necessitates
Health behavior assessment and intervention or two types of
re-assessment; and
health behavior intervention services can be billed on the same
› Changes in goals and/or frequency and duration of services. date of service, but there must be clear documentation of the
• For the intervention services, evidence to support that the provision of the two separate services and documentation of start
intervention is reasonable and necessary (see medical neces- and stop times to distinctly delineate one service from the other.
sity criteria in the Section 1.E) must include, at a minimum, the HBAI codes should only be reported by QHP to identify assess-
following elements: ment and treatment for psychological and/or psychosocial
› Evidence that the patient has the capacity to understand factors affecting a patient’s physical health problems. The HBAI
and to respond meaningfully; guidelines direct that physicians, clinical nurse specialists (CNS),
or nurse practitioners (NP), performing health and behavior
› Clearly defined psychological intervention provided
assessment and/or interventions should report the appropriate
› Clearly stated goals of the psychological intervention code(s) in the Evaluation and Management (E&M) or Preventive
› Documentation that the psychological intervention is Medicine services section of the CPT® manual. (AMA, 2014)
expected to benefit the patient’s physical disease manage- The HBAI CPT code family does not represent preventive medi-
ment and ability to comply with and/or benefit from medi- cine counseling and risk factor reduction interventions. Therefore,
cal interventions they should not be reported for the purpose of prevention of a
› Rationale for frequency and duration of services physical illness or disability, and maintenance of health.
› The response to the intervention The family of Health Behavior services, used for patients with a
primary diagnosis that is physical in nature, have an anomalous
As is noted in the CPT code descriptor language of the health
relationship to Psychotherapy services, used for patients with a
behavior intervention codes, these services are intended to be
primary mental health diagnosis.
reported according to the time spent providing these services.
Therefore, for all claims, start and stop times (stated in minutes) Biofeedback (CPT code 90901; Biofeedback training by any modal-
for the health behavioral intervention encounter should be docu- ity) is not covered as a health behavioral intervention.
mented in the medical record, and the quantity billed should Services to patients for evaluation and treatment of mental
reflect the appropriate number of base and add-on code units illnesses should be coded using psychiatric services CPT codes
required to complete the face-to-face service. (90791-90899).
Performance of a health behavior assessment or re-assessment
includes a health-focused clinical interview, behavioral obser- AMA CPT Health Behavior Assessment and
vations, and clinical decision making. Although the assessment Intervention Guidelines
For complete coding guidance, please refer to Current Proce-
code is an event-based/untimed service, it is recommended that
dural Terminology (CPT®), an AMA annual publication available
start and stop times are documented for the face-to-face time
at https://commerce.ama-assn.org/store/ui.
with the patient(s) and/or family.
Codes in the HBAI series describe services associated with an
© 2019 APA Services Inc. CPT Copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. 8acute or chronic physical illness or symptoms and are offered to UTILIZATION GUIDELINES
patients who may benefit from evaluations that focus on psycho- According to the National Correct Coding Initiative (NCCI) Proce-
logical and/or psychosocial factors. For patients that require dure-to-Procedure (PTP) and Medically Unlikely Edits (MUE)
psychiatric services (90785 - 90899), adaptive behavior services effective January 1, 2020 (CMS/NCCI, 2019):
(97151-97158, 0362T, 0373T) as well as health behavior assess-
• The initial assessment (CPT code 96156) is limited to once (1
ment and intervention, only the predominant service performed
unit) per episode of care.
would be reported.
• The individual intervention is limited to a maximum of 90
Do not report HBAI codes in conjunction with psychiatric services
minutes (1 unit of 96158 and 4 units of 96159) per day, per
(90785-90899) on the same date.
patient.
Evaluation and management (E/M) service codes (including
• The group intervention is limited to a maximum of 120 minutes
counseling risk factor reduction and behavior change interven-
(1 unit of 96164 and 6 units of 96165) per day, per patient.
tion [99401-99412]) should not be reported on the same day as
HBAI codes by the same provider. • The family intervention (with and without patient present) is
limited to a maximum of 120 minutes (1 unit of 96167/96170
HBAI can occur and be reported on the same date of service as
and 6 units of +96168/+96171) per day, per patient.
E/M services, as long as:
Cumulated time is then converted to units of CPT codes reported.
• HBAI is reported by a physician or other QHP; and
A single unit of a base code should be reported with multiple units
• The E/M service is reported by a different physician or other (as needed) of the corresponding add-on code for the individual
QHP that is eligible to perform the services located in the services performed; however, add-on codes can never be reported
E/M or Preventive Medicine Services section of the 2020 as a stand-alone service. They can only be reported in conjunction
CPT® Manual. with their respective base code. (See Addendum A for clinical exam-
In circumstances where telehealth is available and all require- ples and tips for proper documentation, coding and billing.)
ments are met for a psychologist to bill for telehealth services, If a health behavior intervention service exceeds the amount of
Health Behavior Assessment or Re-Assessment (96156), time or number of units allowed for a single service (e.g., as stated
Individual Intervention (96158/+96159), Group Intervention by the NCCI and/or in an insurer policy), documentation must
(96164/+96165), and Family Intervention, when the patient be present in the patient record to justify medical necessity for
is present (96167/+96168), may be furnished via telehealth extended time provided and/or number of units reported.
to Medicare Part B beneficiaries enrolled in fee-for-service
Medicare.
Per CPT guidelines for time-based codes, a unit of service is
attained when the mid-point is passed. For example, 30 minutes
is attained when 16 minutes have elapsed (more than midway
between zero and 30 minutes). Therefore, the following stan-
dards shall apply to time measurement when reporting Health
Behavior Intervention services:
• Do not report 30-minute Health Behavior Intervention base codes
(96158, 96164, 96167, 96170) for less than 16 minutes of service.
• Do not report 15-minute Health Behavior Intervention add-on
codes (96159, 96165, 96168, and 96171) for less than 8
minutes of service.
© 2019 APA Services Inc. CPT Copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. 9care? The Commonwealth Fund. https://www.common-
SOURCES OF INFORMATION
we althf u n d . o r g /p u b lic atio ns / is su e - b rief s / 20 16/a u g /
References high-need-high-cost-patients-who-are-they-and-how-do-they-use
American Diabetes Association. (2018). Mental health provider direc- Highsmith, M. J., Andrews, C. R., Millman, C., Fuller, A., Kahle, J. T.,
tory listing. Retrieved December 13, 2018, from https://professional. Klenow, T. D., Lewis, K. L., Bradley, R. C., & Orriola, J. J. (2016). Gait
diabetes.org/mhp_listing. training interventions for lower extremity amputees: A system-
atic literature review. Technology & Innovation, 18(2–3), 99. DOI:
American Medical Association. (2002). Current Procedural Terminol-
10.21300/18.2-3.2016.99
ogy (CPT®) Assistant. Medicine. Use of the Health and Behavioral
Assessment Codes. Hildebrand, M. W. (2015). Effectiveness of interventions for adults with
psychological or emotional impairment after stroke: An evidence-
American Medical Association. (2004). Current Procedural Terminology
based review. American Journal of Occupational Therapy, 69(1),
(CPT®) Assistant. Medicine, 96150-96155 (Q&A).
6901180050p1–6901180050p9.
American Medical Association. (2009). Current Procedural Terminology
Long, P., Abrams, M., Milstein, A., Anderson, G., Lewis Apton, K., Lund
(CPT®) Assistant. Medicine: Health and Behavior Assessment, Inter-
Dahlberg, M., & Whicher, D. (Eds). (2017). Effective care for high-
vention, 96150 (Q&A).
need patients: Opportunities for improving outcomes, value, and health.
American Medical Association. (2014). Current Procedural Terminology Washington, DC: National Academy of Medicine. https://nam.edu/
(CPT®) Assistant. Medicine: Health and Behavior Assessment/Inter- wp-content/uploads/2017/06/Effective-Care-for-High-Need-Pa-
vention, 96150-96155. tients.pdf
American Medical Association. (2019). Specialty Society Relative Value McDaniel, S. H., Grus, C. L., Cubic, B. A., Hunter, C. L., Kearney, L. K.,
Scale Update Committee Database. Version 2. Schuman, C. C., Karel, M. J., Kessler, R. S., Larkin, K. T., McCutch-
American Medical Association. (2020). Current Procedural Terminology eon, S., Miller, B. F., Nash, J., Qualls, S. H., Connolly, K. S., Stancin, T.,
(CPT®) 2020 Professional Edition. Stanton, A. L., Sturm, L. A., & Johnson, S. B. (2014). Competencies for
psychology practice in primary care. American Psychologist, 69(4),
American Psychological Association. (2016) Resolution on psychologists 409–429. https://doi.org/10.1037/a0036072
in integrated primary care and specialty health settings. http://www.
apa.org/about/policy/integrated-primary-care.aspx Nahin, R. L. (2015). Estimates of pain prevalence and severity in adults:
United States, 2012. The Journal of Pain, 16(8), 769–780. DOI:
American Psychological Association, Clinical Practice Guideline Panel. 10.1016/j.jpain.2015.05.002
(2018). Clinical practice guideline for multicomponent behavioral
treatment of obesity and overweight in children and adolescents: Ponsford, J., Lee, N. K., Wong, D., McKay, A., Haines, K., Alway, Y., Down-
Current state of the evidence and research needs. Retrieved from ing, M., Furtado, C., & O’Donnell, M. L. (2016). Efficacy of motiva-
https://www.apa.org/obesity-guideline/clinical-practice-guide- tional interviewing and cognitive behavioral therapy for anxiety and
line.pdf depression symptoms following traumatic brain injury. Psychological
Medicine, 46(5), 1079–1090. DOI: 10.1017/S0033291715002640
Bosworth, H. B., Blalock, D. V., Hoyle, R. H., Czajkowski, S. M., & Voils,
C. I. (2018). The role of psychological science in efforts to improve Richards S. H., Anderson L., Jenkinson C. E., Whalley B., Rees K., Davies
cardiovascular medication adherence. American Psychologist, 73(8), P., Bennett P., Liu Z., West R., Thompson D. R., & Taylor, R.S. (2018).
968–980. DOI: 10.1037/amp0000316 Psychological interventions for coronary heart disease: Cochrane
systematic review and meta-analysis. European Journal of Preven-
Centers for Medicare and Medicaid Services (2018). Health and tive Cardiology, 25(3), 247–259. DOI: 10.1177/2047487317739978
Behavior Assessment/Intervention – Medical Policy Article
(A52434). Retrieved October 1, 2019, from https://www.cms.gov/ Roditi D. & Robinson M. E. (2011). The role of psychological interven-
medicare-coverage-database/license/cpt-license.aspx?from=~/ tions in the management of patients with chronic pain. Psychology
overview-and-quick-search.aspx&npage=/medicare-coverage-da- Research and Behavior Management, 4, 41–49. DOI: 10.2147/PRBM.
tabase/details/article-details.aspx&articleId=52434&ver=19&Cn- S15375
trctr=All&UpdatePeriod=800&bc=AQAAEAAAAAAA& Russell, H. F., Richardson, E. J., Bombardier, C. H., Dixon, T. M., Huston,
Centers for Medicare and Medicaid Services/National Correct Coding T.A., Rose, J., Sheaffer, D., Smith, S. A., & Ullrich, P. M. (2016). Profes-
Initiative (2019). Quarterly Additions, Deletions, and Modifier sional standards of practice for psychologists, social workers, and
Indicator changes to NCCI PTP Edits for Physicians Practitioners counselors in SCI rehabilitation. The Journal of Spinal Cord Medicine,
Effective January 1, 2020. Quarterly Additions, Deletions, and 39(2), 127–145. https://doi.org/10.1080/10790268.2015.1119966
Revisions to Published MUEs for Practitioner Services Effec- Sogg, S., Laurettie, J., & West-Smith, L. (2016). Recommendations
tive January 1, 2020. Retrieved December 10, 2019, from https:// for the presurgical psychosocial evaluation of bariatric surgery
www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/ patients. Surgery for Obesity and Related Diseases, 12(4), 731–749.
Version_Update_Changes DOI: 10.1016/j.soard.2016.02.008
Hayes, S. L., Salzberg, C. A., McCarthy, D., Radley, D. C., Abrams, Substance Abuse and Mental Health Services Administration-Health
M. K., Shah, T., & Anderson, G. (2016). High-need, high Resources and Services Administration (SAMHSA-HRSA) Center for
cost patients: Who are they and how do they use health Integrated Health Solutions. Primary and behavioral health integration:
© 2019 APA Services Inc. CPT Copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. 10Guiding principles for workforce development. SAMSA-HRSA. U.S. AAA&
Department of Health and Human Services. Retrieved December 10,
Fredrix, M., McSharry, J., Flannery, C., Dinneen, S., & Byrne, M. (2018).
2018, from https://www.integration.samhsa.gov/resource/prima-
Goal-setting in diabetes self-management: A systematic review
ry-and-behavioral-health-integration-guiding-principles-for-work-
and meta-analysis examining content and effectiveness of goal-set-
force-development-cihs
ting interventions. Psychology & Health, 33(8), 955–977. DOI:
The US Burden of Disease Collaborators. (2018). The state of US health, 10.1080/08870446.2018.1432760
1990–2016: Burden of diseases, injuries, and risk factors among US
Hoffman, B. M., Papas, R. K., Chatkoff, D. K., & Kerns, R. D. (2007).
states. JAMA: Journal of the American Medical Association, 319(14),
Meta-analysis of psychological interventions for chronic low back
1444–1472. DOI: 10.1001/jama.2018.0158
pain. Health Psychology, 26(1), 1–9. DOI: 10.1037/0278-6133.26.1.1
Wandner, L. D., Prasad, R., Ramezani, A., Malcore, S. A., & Kerns, R.D.
Optum, United Behavioral Health. (2019). Coverage determination
(2019). Core competencies for the emerging specialty of pain
guideline: Health and behavior assessment & intervention (Document
psychology. American Psychologist, 74(4), 432–444. DOI: 10.1037/
Number: BH803HBAI0618). https://www.providerexpress.com/
amp0000330
content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guide-
Wilfley, D. E., Hayes, J. F., Balantekin K. N., Van Buren, D. J., & Epstein, L. lines/cdg/hba.pdf
H. (2018). Behavioral interventions for obesity in children and adults:
Optum, United Behavioral Health. (2019). Medicare coverage summary:
evidence base, novel approaches, and translation into practice.
Health & behavior assessment and intervention (Document Number:
American Psychologist, 73(8), 981–993. DOI: 10.1037/amp0000293
BH803H&BMCS0319). https://www.providerexpress.com/
Wysocki, T., Harris, M. A., Buckloh, L. M., Mertlich, D., Sobel Lochrie, content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guide-
A., Taylor, A., Sadler, M., Mauras, N., & White, N. H. (2006). Effects lines/mcs/hbaMCS.pdf
of behavioral family systems therapy for diabetes on adolescents’
Robert Wood Johnson Foundation. (2011). Mental Disorders and Medi-
family relationships, treatment adherence, and metabolic control.
cal Comorbidity. Research Synthesis Report No. 21, https://www.
Journal of Pediatric Psychology, 31(9), 928–938. DOI:10.1093/jpepsy/
integration.samhsa.gov/workforce/mental_disorders_and_medi-
jsj098
cal_comorbidity.pdf
Welton, N. J., Caldwell, D. M., Adamopoulos E., & Vedhara, K. (2009).
Additional References Mixed treatment comparison meta-analysis of complex interven-
tions: psychological interventions in coronary heart disease. Ameri-
American Society for Metabolic and Bariatric Surgery. (2018). Esti-
can Journal of Epidemiology, 169, 1158–1165. https://doi.org/10.1093/
mate of bariatric surgery numbers, 2011–2017. https://asmbs.org/
aje/kwp014
resources/estimate-of-bariatric-surgery-numbers
Burns, E. R., Stevens, J. A., & Lee, R. (2016). The direct costs of fatal and
non-fatal falls among older adults—United States. Journal of Safety
Research, 58, 99–103. DOI: 10.1016/j.jsr.2016.05.001
Centers for Medicare & Medicaid Services. (2014). Physical and mental
health condition prevalence and comorbidity among fee-for-service Medi-
care-Medicaid enrollees. https://www.cms.gov/Medicare-Med-
icaid-Coordination/Medicare-and-Medicaid-Coordination/
Medicare-Medicaid-Coordination-Office/Downloads/Dual_Condi-
tion_Prevalence_Comorbidity_2014.pdf
Centers for Medicare & Medicaid Services. (2019) Medicare Benefit
Policy Manual. Retrieved from www.cms.gov/Regulations-and-Guid-
ance/Guidance/Manuals/Downloads/bp102c15.pdf
Centers for Medicare and Medicaid Services (2019). Local Cover-
age Determination (LCD): Health and Behavior Assessment/
Intervention (L33834). Retrieved October 1, 2019, from https://
www.cms.gov/medicare-coverage-database/details/lcd-de-
tails.aspx?LCDId=33834&ver=15&Date=10%2f01%2f2019&Do-
cID=L 33834 & SearchType=Advanced&bc=K A A A ABA A A
AAA&
Centers for Medicare and Medicaid Services (2019). Local Cover-
age Determination (LCD): Health and Behavior Assessment/
Intervention (L37638). Retrieved October 1, 2019, from https://
www.cms.gov/medicare-coverage-database/details/lcd-de-
tails.aspx?LCDId=37638&ver=16&Date=10%2f01%2f2019&Do-
cID=L 37638& SearchType=Advanced&bc=K A A A ABA A A
© 2019 APA Services Inc. CPT Copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. 11You can also read
