Billing and Coding Guide - 2020 Health Behavior Assessment and Intervention

 
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

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clinical 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

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5. 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

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risk-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

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on 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:

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96170; 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

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detailed 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

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acute 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.

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care? 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 /
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