Primary Care Coding Alert

Make sure you pay attention to payer guidelines for 96160/96161.

Health risk assessments (HRAs) and other services attempting to prevent psychological and behavioral factors from impacting a patient’s health look very similar. That’s why there are a number of myths surrounding these small but critical services your physician can provide to your patients.

Sometimes, as in all good myths, there is a grain of truth to them, especially when it comes to payer-specific guidelines. But for the most part, each of the following five myths can be easily debunked, as you are about to see.

Myth 1: Preventive Medicine Services and HRAs are the Same Thing

While the CPT^® guidelines and the code descriptors for preventive evaluation and management (E/M) services 99381-99397 (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 …) do state that they “include counseling/anticipatory guidance/risk factor reduction interventions,” any comparison between preventive medicine E/M services and HRAs 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) ends there.

Simply put, the aim of preventive E/M services is to provide a “comprehensive,” age and gender-appropriate evaluation and management of a patient, including a history, an examination, and ordering laboratory/diagnostic procedures in addition to the counseling/anticipatory guidance/risk factor reduction interventions. HRAs, however, are more focused and involve “collecting and analyzing health-related data…to evaluate the health status or health risk of an individual” according to the Centers for Disease Control and Prevention (CDC) (Source: www.cdc.gov/policy/hst/HRA/FrameworkForHRA.pdf).

Myth 2: Codes 96160/96161 Can Be Used Interchangeably

Actually, the codes differ regarding 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, however, 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 notes.

“We might also see this assessment performed on a caregiver of a patient with a chronic illness such as Alzheimer’s or cancer, to assess anxiety, depression, stress, and so on that might affect the quality of care the patient is receiving,” Bucknam explains. And it would also be appropriate for you to use 96161 in cases where a parent/guardian is struggling to care for an intellectually disabled patient.

Myth 3: Codes 96160/96161 and 96127 Can Be Used Interchangeably for Depression Screenings

Actually, this myth is partly true. You can use 96160/96161 and 96127 (Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument) for depression screenings, but code choice may be payer specific.

“Some payers require reporting 96160 for depression screening other than postpartum depression, even though 96127 is intended for reporting this service,” according to Cindy Hughes, CPC, CFPC, consulting editor of Cindy Hughes Consulting in El Dorado, Kansas. Additionally, “some payers require reporting 96127 for CRAFFT [Care, Relax, Alone, Forget, Friends, Trouble] and HEEADSSS [Home, Education, Eating, Activities, Drugs and Alcohol, Suicide and Depression Sexuality and Safety] screenings,” Hughes notes.

Myth 4: Health Behavior Assessments and HRAs Are the Same Thing

This myth comes from the confusing similarity between the wording for 96160/96161 and 96156 (Health behavior assessment, or re-assessment (ie, health-focused clinical interview, behavioral observations, clinical decision making)). In fact, health behavior assessments and HRAs are very different, and health behavior assessments require a lot more work on behalf of the provider.

While HRAs are generally conducted using screening tools, “a health behavior assessment is conducted using health-focused interviews, behavioral observation, and clinical decision making. Health behavior assessments include evaluating the patient’s responses to disease, illness or injury, outlook, coping strategies, motivation, and adherence to medical treatment,” according to CPT^® Assistant Vol. 30, Issue 8 (August 2020).

This accounts for the different work values for the services, with Medicare valuing the 2021 nonfacility fees for 96156 at $97.35 and $2.79 for 96160/96161 respectively. In fact, Medicare assigns no work relative value units (RVUs) to either 96160 or 96161, and both codes have only minimal practice expense RVUs under the Medicare physician fee schedule.

Myth 5: HRAs Cannot Be Separately Reported from Other Services

This final myth is easily busted. 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 99381-99397, and no CPT^® regulations prohibit these 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. So again, checking your payer’s guidelines before reporting 96160 or 96161 is definitely a good idea.

The HRA codes are subject to PTP edits when reported with the other screening and assessment codes, however. For example, NCCI considers 96160 and 96161 to be column 2 codes to column 1 code 96127 and thus components of brief emotional/ behavioral assessment services, though NCCI assigns the PTP pairs a modifier indicator of 1, meaning 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.