Psychiatry Coding & Reimbursement Alert

Watch documentation to check face-to-face time with the patient.

When your clinician performs health and behavioral intervention for a patient with an underlying physical illness, you will need to focus on whether the service was for just one patient or for a group. You should also look at whether or not the patient’s family was present during the encounter, as it affects your code choice.

According to CPT^® guidelines, health and behavioral intervention procedures are used to improve the patient’s health and well-being using cognitive, behavioral, social, and/or psychophysiological procedures designed to ameliorate specific disease-related problems.

“Per CPT^®, these codes describe services offered to patients who present with primary physical illnesses, diagnoses, or symptoms and may benefit from assessments and interventions that focus on the biopsychosocial factors related to their health status,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “These services do not represent preventive medicine counseling and risk factor reduction interventions.” When your clinical psychologist performs health and behavioral intervention, you report it with the following four codes, depending on whether your clinician is performing the intervention with just one patient or for a group or with the family of the patient:

• 96152 (Health and behavior intervention, each 15 minutes, face-to-face; individual)
• 96153 (…group [2 or more patients])
• 96154 (…family [with the patient present])
• 96155 (…family [without the patient present])

If your clinician is performing the intervention with only one patient, you should choose 96152. If more than one patient is present, you should use the group code, 96153. If the family of the patient is present with the patient during the intervention, then you should report 96154. If only the patient’s family is present during the session and the patient is not present during the session, you should report 96155. However, you will not receive reimbursement if you are trying to report 96155 to many payers, especially Medicare.

Understand The Criteria For Health and Behavioral Intervention Codes

As indicated in some Medicare local coverage determinations (LCDs), you can report the health and behavioral intervention codes (96152 or 96153), only if all the following criteria are met:

• The patient has an underlying physical illness or injury, 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
• Specific psychological intervention(s) and patient outcome goal(s) have been clearly identified
• Psychological intervention is necessary to address:

Non-compliance with the medical treatment plan, or
The biopsychosocial factors associated with a newly diagnosed physical illness, or an exacerbation of an established physical illness, when such factors affect symptom management and expression, health-promoting behaviors, health-related risk-taking behaviors, and overall adjustment to medical illness.

You can report 96154 only if the following criteria are met:

The family representative directly participates in the overall care of the patient, and

The psychological intervention with the patient and family is necessary to address biopsychosocial factors that affect compliance with the plan of care, symptom management, health-promoting behaviors, health-related risk-taking behaviors, and overall adjustment to medical illness.

Base Health and Behavioral Intervention Reporting on Time

When your clinical psychologist performs health and behavioral intervention, you report codes (96152-96154) based on time spent face-to-face with the patient. According to the descriptor to these codes, you will have to report one unit of the code for every 15 minutes your clinician spends with the patient.

Any time spent in any interpretation of questionnaires presented to the patient prior to the intervention should not be counted when calculating the time component of the intervention code. For instance, suppose your psychologist spends 15 minutes prior to performing the intervention in interpretation of questionnaires presented to the patient during assessment. He then spends another 30 minutes face-to-face with the patient for the intervention. You can only count the 30 minutes spent face-to-face with the patient and not the 15 minutes spent prior to the intervention. So, you will only report 96152 x 2 in this instance and not 96152 x 3.

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.

Know the Service Provider Requirements for Health and Behavior Intervention Codes

According to CPT^® guidelines and at least some Medicare LCDs that have been issued, health and behavioral assessment codes, 96152-96154 can be reported only when the intervention has been performed by a non-physician provider who may not report evaluation and management (E/M) services (e.g., clinical psychologist [CP- Medicare specialty code 68] or a licensed clinical social worker [LCSW – Medicare specialty code 80].

If similar services are provided by your psychiatrist or other physicians, you cannot report the service using health and behavioral intervention codes, 96152-96154. Instead, you will have to report the service with the most appropriate 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 96152-96154. Instead, an 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 Same Day Assessment and Intervention Codes Can be Reported

If your psychologist is performing health and behavioral assessment and intervention on the same calendar date of service, you will have to shift focus toward Correct Coding Initiative (CCI) edits as you will face bundling if you are trying to report both assessment and intervention codes together. If you are looking at reporting health and behavioral assessment code 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) with intervention codes (96152-96154), you will face bundling edits.

As the modifier indicator to this bundling is ‘1,’ you can overcome the edit by using a suitable modifier. The modifier that you will have to use is 59 (Distinct procedural service). Since intervention codes are the column 2 codes in the edit bundle with 96150, you will have to append the modifier to the intervention codes.

If your clinician is performing a re-assessment and intervention on the same day, the edit bundles will be reversed. Here the re-assessment code, 96151 (…re-assessment) will form the column 2 code in the edit bundle with intervention codes. So, you will have to append the modifier to 96151 to overcome the edit with codes, 96152-96154.

Coding tip: As with assessment codes, health and behavioral intervention codes (96152-96154) cannot be reported with any other psychiatry related codes for the same calendar date of service. These edits carry the modifier indicator ‘0,’ which means that you cannot overcome the edit bundle under any circumstances. “For patients that require psychiatric services and health and behavior assessment/intervention, CPT^® advises you to report the predominant service performed,” Moore observes.