Billing and Coding Guide - 2020 Health Behavior Assessment and Intervention
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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. 2
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 © 2019 APA Services Inc. CPT Copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. 3
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 © 2019 APA Services Inc. CPT Copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. 4
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 © 2019 APA Services Inc. CPT Copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. 5
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: © 2019 APA Services Inc. CPT Copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. 6
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 © 2019 APA Services Inc. CPT Copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. 7
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 © 2019 APA Services Inc. CPT Copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. 8
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. © 2019 APA Services Inc. CPT Copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. 9
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