Pediatric Coding Alert

Because health risk assessments (HRAs) appear so similar to other assessment services, using the HRA codes can be a real gamble.

But you can quickly learn to use screening and assessment codes effectively and accurately. All you have to do is learn the answers to these frequently asked questions.

What Is a Health Risk Assessment?

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. However, only 96160/96161 involve administering, scoring, and documenting a standardized instrument.

What Counts as a Standardized Instrument?

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.

Coding Alert 1: “Some payers require reporting 96127 for HEEADSSS and CRAFFT screenings,” Hughes notes.

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.

Coding Alert 3: Some payers “require reporting 96160 for depression screening other than postpartum depression, even though 96127 is intended for reporting this service,” Hughes adds.

How Do 96160/96161 Differ From Each Other?

Simply put, the two differ over who is being assessed. 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.

Code 96161, on the other hand, assesses “a caregiver for the patient, not the patient him/herself, when the caregiver may have a condition that is affecting the patient. For example, the assessment might be done on a new mother to see if there is any problem, such as postpartum depression, that could affect the care of the patient,” Bucknam adds.

How Do 96160/96161 Differ From Other Screening and Assessment Codes?

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 assessment … with scoring and documentation, per standardized instrument).

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^®. So, 96110 and 96127 are used whenever your provider is assessing a patient’s psychological and neuropsychological condition, such as a patient’s “memory, language, visual motor responses, and abstract reasoning/ problem-solving abilities,” whereas 96160/96161 are used whenever your provider is assessing how a psychological condition is impacting a patient’s health condition (96160) or how the patient’s caregiver’s psychological condition may affect the caregiver’s ability to care for the patient (96161).

In other words, HRAs identify “patients’ modifiable health risks,” which then allows a pediatrician to then provide “follow-up behavior change interventions” and “improve health outcomes,” according to the Centers for Disease Control and Prevention (CDC) (Source: https://www.cdc.gov/policy/hst/HRA/FrameworkForHRA.pdf).

Are HRAs Bundled Into E/Ms or Other Services?

National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits do not bundle 96160 and 96161 into the office/outpatient evaluation and management (E/M) codes 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) or the preventive medicine E/M codes 99381-99396 (Initial/periodic comprehensive preventive medicine evaluation/reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new/established patient …), and no CPT^® regulations prohibit the services from being reported together. 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.

The HRA codes are subject to PTP edits when reported with the other screening and assessment codes, however. When 96160 and 96161 are column 1 codes to 96127 and 96110, NCCI considers the column 2 codes as components of the HRA services, though as NCCI assigns the PTP pairs modifier indicators of 1, the edits may be overridden with an NCCI-associated modifier when appropriate.

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.