Psychiatry Coding & Reimbursement Alert

Hint: Don’t combine this service with other psychiatric treatments.

When your clinician performs health and behavioral assessment for a patient with an underlying physical illness, you will need to focus on who the provider is (psychologist or psychiatrist) to zone in on the right codes to report for this service. You should also look into documentation to check face-to-face time as it affects the number of units of the code that you will report.

According to CPT® guidelines, health and behavioral assessment procedures are used to identify the psychological, behavioral, emotional, cognitive, and social factors important to the prevention, treatment, or management of physical health problems. The focus of the assessment is not on mental health but on the biopsychosocial factors important to physical health problems and treatments.

When your clinical psychologist performs health and behavioral assessment, you report it with the following two codes depending on whether your clinician is performing an initial assessment or a reassessment:

• 96150 (Health and behavior assessment [e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires], each 15 minutes face-to-face with the patient; initial assessment)

• 96151 (…re-assessment)

Know The Criteria For Health and Behavioral Assessment Codes

As indicated in some Medicare local coverage determinations (LCDs), you can report the health and behavioral assessment codes, 96150 or 96151 only if all the following criteria are met:

• The patient has an underlying physical illness or injury, and

• The purpose of the assessment is not for the diagnosis or treatment of mental illness, and

• There are indications that biopsychosocial factors may be significantly affecting the treatment or medical management of an illness or an injury, and

• The patient is alert, oriented and has the capacity to understand and to respond meaningfully during the face-to-face encounter, and

• The patient has a documented need for psychological support to successfully manage his/her physical illness, and activities of daily living, and

• The assessment is not duplicative of other provider assessments

Note That 96150 and 96151 are Time Based Codes

If your clinician is performing a health and behavioral assessment of a patient, you will have to report one unit of the assessment code for every 15 minutes that your psychologist is spending with the patient. Note that the time that your clinician spends for the assessment is only for the time spent face-to-face with the patient and not for the time that he might spend on the interpretation of the questionnaires that he presents to the patient.

For instance, your clinical psychologist is performing an initial health and behavioral assessment and spends a total of one hour face-to-face with the patient in the interview, monitoring and getting the patient to answer some questionnaires for the assessment. He then spends another 15 minutes in the interpretation of the questionnaires. Since only the time spent face-to-face with the patient can be counted for calculating the number of units of the code, you will only take into account the one hour spent with the patient and not the additional 15 minutes in the interpretation. So, you will report 96150 x 4 in this instance and not 96150 x 5.

Coding tip: If your clinician extends the assessment of the patient over more than one calendar date of service, the date of service on the claim should be the date on which the interview was finalized.

Understand Service Provider Requirements For 96150 and 96151

According to CPT® guidelines and at least some Medicare LCDs that have been issued, health and behavioral assessment codes, 96150 and 96151 can be reported only when the assessment has been performed by a clinical psychologist (CP- Specialty code 68).

If similar services are provided by your psychiatrist or other physicians, you cannot report the service using health and behavioral assessment codes, 96150 and 96151. Instead, you will have to report the service with the most appropriate evaluation and management(E/M) code or with an appropriate preventive medicine services code. Also, per CPT®, if the service is provided by a qualified health care professional who may report E/M services, such as clinical nurse specialist (CNS) or nurse practitioner (NP), you should not report 96150 or 96151. Instead, appropriate E/M code or preventive medicine services code should be reported.

For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

Check if Other Psychiatric Same Day Services Can Be Reported

If your clinical psychologist performs health and behavioral assessment of a patient, you cannot report any other psychiatry related codes for the same calendar date of service. If you are looking at reporting any psychiatry related codes (such as psychodiagnostic evaluation, 90791 [Psychiatric diagnostic evaluation] or a psychotherapy code, 90832 [Psychotherapy, 30 minutes with patient and/or family member]), you will run into edits. 

Correct Coding Initiative (CCI) edits will not allow you to report health and behavioral assessment codes with other psychiatry codes for the same patient on the same calendar date of service. These edits carry the modifier indicator ‘0,’ which means that you cannot overcome the edit and use a modifier to report both the codes together. If you try reporting either 96150 or 96151 with any other psychiatry related code, your claim for the health and behavioral assessment will be denied and only the reimbursement for the psychiatry code will be paid out.

“These edits are consistent with CPT® guidelines that state health and behavior assessment codes should not be reported in conjunction with psychiatric service codes on the same date,” observes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “CPT® advises that when patients require psychiatric services as well as health and behavior assessment, you should report the predominant service performed. Since many of the psychiatry codes are also time-based, one way to determine which was predominant is to note which took the most time with the patient,” Moore adds.