Clarification was made to the Health and behavioral assessment and Health and behavioral intervention. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. To report, see 96127, 96136, 96137, 96138, 96139. This is often included in the test itself, but these elements may alternatively be documented in the progress report of the visit itself. Because of the impact on the medical management of the patients disease, documentation must show evidence of coordination of care with the patients primary medical care provider or medical provider responsible for the medical management of the physical illness that the psychological assessment/intervention was meant to address. Code 99483 provides reimbursement to physicians and other eligible billing practitioners for a comprehensive clinical visit that results in a written care plan . The code lists in the article help explain which services (procedures) the related LCD applies to, the diagnosis codes for which the service is covered, or for which the service is not considered reasonable and necessary and therefore not covered. Health and behavioral intervention is the promotion of functional improvements in the patients psychological and psychosocial condition. Documentation Requirements All documentation must be maintained in the patient's medical record and made available to the contractor upon request. For re-assessment, detailed progress notes must include the following elements: Date of change in mental or physical status, Clear rationale for why re-assessment is required, Clear indication of the precipitating event that necessitates re-assessment, and, Changes in goals, duration and/or frequency and duration of services. Local Coverage Articles are a type of educational document published by the Medicare Administrative Contractors (MACs). Adapted from Getting Paid for Screening and Assessment Services.. Both 96110 and 96127 reside in the central nervous system assessments/tests code group (96105-96146) and are used to report the services provided during testing of the central nervous system functions, per CPT. An asterisk (*) indicates a Diagnosis code Z00.129, Encounter for routine child health examination without abnormal findings, is linked to each service reported as this code includes an encounter for developmental screening. CPT 96127: This code is used for the administration of a brief emotional/behavioral assessment with scoring and documentation. This code may also be reported for depression screening in adult patients other than Medicare beneficiaries. Self-Administered Drug (SAD) Exclusion List articles list the CPT/HCPCS codes that are excluded from coverage under this category. Applicable FARS\DFARS Restrictions Apply to Government Use. What Counts as a Standardized Instrument? CMS believes that the Internet is "JavaScript" disabled. Do not report preparation and scoring separately. The results are documented in the medical record. How Do 96160/96161 Differ From Each Other? CRs are not policy, rather CRs are used to relay instructions regarding the edits of the various claims processing systems in very descriptive, technical language usually employing the codes or code combinations likely to be encountered with claims subject to the policy in question. This year CPT has added code 99211 to the list and included patient- and caregiver-focused health risk assessment codes 96160 and 96161. Article revised and published on 9/9/2021 effective for dates of service on and after 01/01/2020 in response to an inquiry for clarification to the article. CPT codes 96158, 96164, and 96167 should not be reported for less than 16 minutes of service. CPT is a registered trademark of the American Medical Association.". Depression screening, reported with 96127, is typically a covered preventive service for adolescents age 12 to 18 and is a quality measure in many pediatric quality initiatives. But you can quickly learn to use screening and assessment codes effectively and accurately. Only the preventive medicine E/M service code, reported with ICD-10 codes Z00.01, F32.1, and Z13.89, is reimbursed. Codes 96110, 96160, and 96161 are typically limited to developmental screening and the health risk assessment (HRA). In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice. The AMA does not directly or indirectly practice medicine or dispense medical services. preparation of this material, or the analysis of information provided in the material. AHA copyrighted materials including the UB‐04 codes and All Rights Reserved. The requirements to report either 96160 or 96161 are as follows: Practice expense is incurred to administer the instrument (such as nurse time or for purchase of the screen). 2. Specifically, CPT code 96160 describes the administration of patient-focused health risk assessment instruments with scoring and documentation, per standardized instrument. As used herein, "you" and "your" refer to you and any organization on behalf of which you are acting. Compliance with the provisions in LCD L33834, Health and Behavior Assessment/Intervention may be monitored and addressed through post payment data analysis and subsequent medical review audits. Coding Alert 2: If your pediatrician also provides an intervention for alcohol or substance abuse, you would report codes 99408 (Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes) and 99409 ( greater than 30 minutes) depending on time, Hughes cautions. As clinical or administrative codes change or system or policy requirements dictate, CR instructions are updated to ensure the systems are applying the most appropriate claims processing instructions applicable to the policy. ET), 2023 Annual Clinical & Scientific Meeting, Congressional Leadership Conference (CLC), Coding Question: Postpartum Depression Screening, Alliance for Innovation on Maternal Health, Postpartum Contraceptive Access Initiative. Developmental screening reported with code 96110 is paid for by 45 state Medicaid programs with rates varying from approximately $5 to $60.1 Many private insurers also provide preventive benefits for code 96110 for developmental screening at nine months, 18 months, and 30 months, and autism screening at 18 months and 24 months in addition to the recommended preventive medicine E/M services (e.g., well-child visits). Federal government websites often end in .gov or .mil. Applicable Federal Acquisition Regulation Clauses (FARS)/Department of Defense Federal Acquisition Regulation supplement (DFARS) Restrictions Apply to Government Use. But some brief assessment instruments such as the Epworth Sleepiness Scale may be considered an HRA by some payers but bundled with a diagnostic E/M service by others, Hughes cautions. Report the additional CPT code (99202-99205 and 99211-99215) with modifier -25. Report CPT code 90791 for the psychiatric diagnostic interview and G0396 indicating the performance of 15-30 minutes of SBIRT services. 2) Try using the MCD Search and enter your information in the "Enter keyword, code, or document ID" box. Per CPT, standardized instruments are validated tests that are administered and scored in a consistent or standard manner consistent with their validation. For 96160, that would include such tests as the Mini Nutritional Assessment-Short Form; Sport Concussion Assessment Tool (SCAT 5-); Alcohol Use Disorders Identification Test; Care, Relax, Alone, Forget, Friends, Trouble (CRAFFT); and Home, Education, Eating, Activities, Drugs and Alcohol, Suicide and Depression Sexuality and Safety (HEEADSSS), while standardized tests appropriate for 96161 include the Safe Environment for Every Kid; Caregiver Strain Index; and Edinburgh Postnatal Depression Scale, according to Cindy Hughes, CPC, CFPC, consulting editor of Cindy Hughes Consulting in El Dorado, Kansas. If you dont find the Article you are looking for, contact your MAC. Applications are available at the American Dental Association web site. Heres your chance to prove you know your way around the F01-F99 codes. Review the article, in particular the Coding Information section. This code is used when a healthcare provider administers a standardized questionnaire to a patient to help identify specific health risks, analyzes the results, assigns a score, and documents the findings. In order for CMS to change billing and claims processing systems to accommodate the coverage conditions within the NCD, we instruct contractors and system maintainers to modify the claims processing systems at the national or local level through CR Transmittals. Author disclosure: no relevant financial affiliations disclosed. When reporting multiple units of the same or different screening instruments, modifier 59, XE, XP, XS, or XU may be required to indicate distinct services. Heres your guide to risk-free screening and assessment coding. CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. This blog is not intended to provide medical, financial, or legal advice. Related policy n/a References Center for Disease Control and Prevention (CDC). All you have to do is learn the answers to these frequently asked questions. The American Hospital Association ("the AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. CDT is a trademark of the ADA. Instrument-based assessment of the patient's risk for certain health conditions, behaviors that may negatively impact health, and pros and cons for initiating behavior change, Mini Nutritional Assessment - Short Form, Acute Concussion Evaluation, Alcohol Use Disorders Identification Test, CRAFFT (Care, Relax, Alone, Forget, Friends, Trouble), and HEE-ADSSS (Home, Education, Eating, Activities, Drugs and Alcohol, Suicide and Depression, Sexuality and Safety). Explanation of Revision: Annual 2020 HCPCS Update. A Draft article will eventually be replaced by a Billing and Coding article once the Proposed LCD is released to a final LCD. Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. When reporting CPT codes 96159, 96165, and 96168, the quantity billed should reflect 1 unit for each 15 minutes. CPT codes 96150, 96151, 96152, 96153, 96154, and 96155 were deleted. Do not reportCPT codes 96156, 96158, 96159, 96164, 96165, 96167 and 96168 in addition to codes for psychiatry services on the same date. It is conducted through health focused interviews, observations, and clinical decision making. 4) Visit Medicare.gov or call 1-800-Medicare. All documentation must be maintained in the patient's medical record and made available to the contractor upon request. No modifier is necessary because the commercial payer does not bundle 96110 with 99392 and allows two units per date of service as the maximum allowable for code 96110. (You may have to accept the AMA License Agreement.) These codes do not represent physician work. 96160 96161 CPT 96160, Under Health Behavior Assessment and Intervention Procedures The Current Procedural Terminology (CPT ) code 96160 as maintained by American Medical Association, is a medical procedural code under the range - Health Behavior Assessment and Intervention Procedures. Medicaid and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration The views and/or positions presented in the material do not necessarily represent the views of the AHA. See permissionsforcopyrightquestions and/or permission requests. The submitted CPT/HCPCS code must describe the service performed. The physician reports preventive medicine E/M code 99395 with ICD-10 code Z00.01, Routine adult medical examination with abnormal findings, and F32.1, Major depressive disorder, single episode, moderate. Also reported to the patient's health plan is code 96127 for the depression screening with ICD-10 diagnosis code Z13.89 Encounter for screening for other disorder. If a significant, separately identifiable E/M service was rendered for depression or another health problem, an established patient office or other outpatient service code would be separately reported with modifier 25 appended. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. However, if the physician diagnoses depression, you may report it separately since the global package was valued for uncomplicated antepartum, delivery, and postpartum care. The physician recommends a consultation with a psychologist for management of moderate major depression, and a staff member arranges the appointment for later in the week. accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the For instance, one plan in Tennessee has paid. Complete absence of all Bill Types indicates No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be Who Is Covered. CPT 96161: This code is used for the administration of a caregiver-focused health risk assessment instrument, such as a depression inventory, for the benefit of the patient. Report code 96161 for a health risk assessment when focused on care-giver risk that may impact the patient's health (e.g., postpartum depression). End User License Agreement: DOCUMENTATION GUIDELINES 96110 Each administered developmental screening instrument is accompanied by scoring and documentation (eg, a score or designation as normal or abnormal). End Users do not act for or on behalf of the CMS. . You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. Clinical staff administer and score a structured screening instrument for depression with positive results. Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Do your [], Heres your guide to risk-free screening and assessment coding. CPT is a trademark of the American Medical Association (AMA). For this supplementary claims processing information we rely on other CMS publications, namely Change Requests (CR) Transmittals and inclusions in the Medicare Fee-For-Service Claims Processing Manual (CPM). For the most part, codes are no longer included in the LCD (policy). If a redetermination is requested, documentation showing the CPT code 96160 allows allergists to get reimbursed when they make use of certain standardized asthma assessment instruments. Both 96110 and 96127 reside in the central nervous system assessments/tests code group (96105-96146) and are used to report the services provided during testing of the central nervous system functions, per CPT. Diagnostic Radiology (Diagnostic Imaging), Genomic Sequencing and Molecular Multianalyte Assays, Multianalyte Assays With Algorithmic Analyses, Immunization Administration for Vaccines/Toxoids, Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration, Physical Medicine and Rehabilitation Evaluations, Education and Training For Patient Self-Management, Special Services, Procedures, and Reports (Miscellaneous Medicine), Case Management (Medical Team Conferences), Non-Face-to-Face Evaluation and Management, Delivery/Birthing Room Attendance and Resuscitation, Inpatient Neonatal and Paediatric Critical Care, (2022) Billing Guidelines For Reclast, Zometa (Concentrate), And Aclasta, How To Bill Medical Records Requests | Descriptions & Billing Guidelines (2022), Ambulance Modifiers & Codes | How To Bill Ambulance Services (2022), HCPCS Code l3908 | Description & Billing Guidelines, ICD 10 CM S06.377A | Description & Clinical Information, ICD 10 CM S62.209D | Description & Clinical Information, ICD 10 CM S14.106S | Description & Clinical Information. Code 96160 is for the patient, who may have risks that impact their health but that have not yet been diagnosed, says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington. This is particularly true if the physician routinely screens every patient for depression. The HRA codes 96160 (Administration of patient-focused health risk assessment instrument [eg, health hazard appraisal] with scoring and documentation, per standardized instrument) and 96161 (Administration of caregiver-focused health risk assessment instrument [eg, depression inventory] for the benefit of the patient, with scoring and documentation, per standardized instrument) like all the health behavior assessment and intervention codes (96156-96161) are used to identify and address the psychological, behavioral, emotional, cognitive, and interpersonal factors important to the assessment, treatment, or management of physical health problems, according to CPT guidelines. ICD-10-CM Codes that Support Medical Necessity, ICD-10-CM Codes that DO NOT Support Medical Necessity, L33834 - Health and Behavior Assessment/Intervention, HEALTH BEHAVIOR ASSESSMENT, OR RE-ASSESSMENT (IE, HEALTH-FOCUSED CLINICAL INTERVIEW, BEHAVIORAL OBSERVATIONS, CLINICAL DECISION MAKING), HEALTH BEHAVIOR INTERVENTION, INDIVIDUAL, FACE-TO-FACE; INITIAL 30 MINUTES, HEALTH BEHAVIOR INTERVENTION, INDIVIDUAL, FACE-TO-FACE; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE), ADMINISTRATION OF PATIENT-FOCUSED HEALTH RISK ASSESSMENT INSTRUMENT (EG, HEALTH HAZARD APPRAISAL) WITH SCORING AND DOCUMENTATION, PER STANDARDIZED INSTRUMENT, ADMINISTRATION OF CAREGIVER-FOCUSED HEALTH RISK ASSESSMENT INSTRUMENT (EG, DEPRESSION INVENTORY) FOR THE BENEFIT OF THE PATIENT, WITH SCORING AND DOCUMENTATION, PER STANDARDIZED INSTRUMENT, HEALTH BEHAVIOR INTERVENTION, GROUP (2 OR MORE PATIENTS), FACE-TO-FACE; INITIAL 30 MINUTES, HEALTH BEHAVIOR INTERVENTION, GROUP (2 OR MORE PATIENTS), FACE-TO-FACE; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE), HEALTH BEHAVIOR INTERVENTION, FAMILY (WITH THE PATIENT PRESENT), FACE-TO-FACE; INITIAL 30 MINUTES, HEALTH BEHAVIOR INTERVENTION, FAMILY (WITH THE PATIENT PRESENT), FACE-TO-FACE; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE), Some older versions have been archived. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. Several CPT codes will be permitted through audioonly telehealth after 5/11/2023. CPT 96160 is a code used for the administration of patient-focused health risk assessment instruments, including scoring and documentation. By clicking below on the button labeled "I accept", you hereby acknowledge that you have read, understood and agreed to all terms and conditions set forth in this agreement. The physician completes the age- and gender-appropriate history and exam, including a review of the scores of the screening instruments, and provides counseling/anticipatory guidance and/or identifies the need for diagnostic testing as indicated. In addition, most are recommended preventive services, and some may also be factored into performance ratings and quality initiatives. For assessments of specific risks such as caregiver strain, report code Z13.89. American College of Obstetricians and Gynecologists The CPT guidelines for 96156-96161 provide an important reminder about how 96160/96161 differ from two other screening and assessment codes: 96110 (Developmental screening [eg, developmental milestone survey, speech and language delay screen] with scoring and documentation, per standardized instrument) and 96127 (Brief emotional/behavioral Code96146, Psychological or neuropsychological test administration, with single automated, standardized instrument via electronic platform, with automated result only, should be reported once per session (CPT Assistant, October 2018). In this article, we will review the documentation and billing requirements necessary for getting paid. A healthcare provider administers a mental health risk assessment questionnaire to a patient experiencing high levels of stress. The contractor information can be found at the top of the document in the, Please use the Reset Search Data function, found in the top menu under the Settings (gear) icon. s an evaluation of psychological, behavioral, emotional, cognitive and social factors that affect the patients response. Simply put, the two differ over who is being assessed. of the Medicare program. recipient email address(es) you enter. All rights reserved. Example: An 18-month-old established patient is seen for a well-child exam. Please do not use this feature to contact CMS. When more than four CPT codes 96150 are submitted by a provider/group the additional services will be denied. The 96160 CPT code procedure involves the following steps: Patients eligible to receive CPT code 96160 services are those who may be at risk for developing specific health issues or conditions. 21) Enter the code you're looking for in the "Enter keyword, code, or document ID" box. For more information, visit Getting Paid for Screening and Assessment Services at www.aafp.org/fpm/2017/1100/fpm20171100p25.pdf and A Framework for Patient-Centered Health Risk Assessments at www.cdc.gov/policy/hst/HRA/FrameworkForHRA.pdf. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. that coverage is not influenced by Bill Type and the article should be assumed to Quick reference: Screening and assessment codes, Screening Your Adult Patients for Depression, Childhood instrument-based screening for failure to develop and/or achieve skills according to the expected time frame (e.g., expressive and receptive language, motor skills), Ages & Stages Questionnaires Third Edition, Parents' Evaluation of Developmental Status, and Modified Checklist for Autism in Toddlers Revised With Follow-Up. When using Edinburgh Postnatal Depression Screening to screen for depression in pregnant or postpartum patients, it is more appropriate to report CPT code 96160, Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument. Your email address will not be published. Revenue Codes are equally subject to this coverage determination. There are no diagnosis code limitations being applied at this time. For the intervention service, progress notes must include, at a minimum, the following elements: Evidence that the patient has the capacity to understand and to respond meaningfully, and, Clearly defined psychological intervention planned, and, The goals of the psychological intervention should be stated clearly, There should be documentation that the psychological intervention is expected to improve compliance with the medical treatment plan, and, Rationale for frequency and duration of services. If you need an accommodation or require documents in another format, please call 1-800-562- 3022. 6. Before sharing sensitive information, make sure you're on a federal government site. MACs are Medicare contractors that develop LCDs and Articles along with processing of Medicare claims. G0438 - Initial visit. Look for a Billing and Coding Article in the results and open it. without the written consent of the AHA. What Counts as a Standardized Instrument? The views and/or positions The physician's interpretation of the score in light of the patient presentation is considered part of the evaluation and management (E/M) service, which would be billed in addition to the screening or assessment code. If you are having an issue like this please contact, You are leaving the CMS MCD and are being redirected to the CMS MCD Archive that contains outdated (No Longer In Effect) Local Coverage Determinations and Articles, You are leaving the CMS MCD and are being redirected to, Billing and Coding: Health and Behavior Assessment/Intervention, AMA CPT / ADA CDT / AHA NUBC Copyright Statement. If you need more information on coverage, contact the Medicare Administrative Contractor (MAC) who published the document. If that doesnt work please contact, Technical issues include things such as a link is broken, a report fails to run, a page is not displaying correctly, a search is taking an unexpectedly long time to complete. A few payers do indicate that a report (separate from the E/M service documentation) is also required, so verify your payers' documentation requirements prior to providing these services. Please refer to the Local Coverage Article: Billing and Coding: Health and Behavior Assessment/Intervention (A57754) for documentation requirements that apply to the reasonable and necessary provisions outlined in this LCD. Coding Alert 1: Some payers require reporting 96127 for HEEADSSS and CRAFFT screenings, Hughes notes. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or Disclaimer: The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians.
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