This First Coast Billing and Coding Article for Local Coverage Determination (LCD) L33834 Health and Behavior Assessment/Intervention provides billing and coding guidance for frequency limitations as well as diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in the LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
Refer to the LCD for reasonable and necessary requirements and limitations.
The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in the LCD.
Coding 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.
Health and behavioral intervention procedures are used to modify the psychological, behavioral, emotional, cognitive, and social factors identified as important to or directly affecting the patient’s physiological functioning, disease status, health, and well being.
The guidelines of the Correct Coding Initiative (CCI) supersede all coding instructions in this Billing and Coding Article. The CPT codes 96156, 96158, 96159, 96164, 96165, 96167 and 96168 may be used only by a Clinical Psychologist (CP), (Specialty Code 68).
For patients who require psychiatry services or adaptive behavior services as well as health and behavior assessment and intervention (CPT codes 96156, 96158, 96159, 96164, 96165, 96167 and 96168), report the predominant service performed. Do not report CPT codes 96156, 96158, 96159, 96164, 96165, 96167 and 96168 in addition to codes for psychiatry services on the same date.
ICD-10 CM diagnosis code(s) reflecting the physical condition(s) being treated must be present on the claim as the primary diagnosis.
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
Documentation Requirements
- All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
- The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
- Because of the impact on the medical management of the patient’s disease, documentation must show evidence of coordination of care with the patient’s 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.
- Evidence of a referral to the Clinical Psychologist by the medical provider responsible for the medical management of the patient’s physical illness or verification of a recommendation from the medical provider to the Clinical Psychologist, obtained by request and review of the permanent medical record, must be documented in the medical record for the initial assessment and for reassessment.
- Documentation in the medical record by the Clinical Psychologist (CP) must include:
- For the initial assessment, progress notes must include at a minimum the following elements:
- Onset and history of initial diagnosis of physical illness, and
- Clear rationale for why assessment is required, and
- Assessment outcome including mental status and ability to understand or respond meaningfully, and
- Goals and expected duration of specific psychological intervention(s), if recommended.
- 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
- 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
For all claims, time duration (stated in minutes) spent in the health and behavioral assessment or intervention encounter should be documented in the medical record. When reporting CPT codes 96159, 96165, and 96168, the quantity billed should reflect 1 unit for each 15 minutes. CPT codes 96158, 96164, and 96167 should not be reported for less than 16 minutes of service.
Medical records need not be submitted with the claim; however, the medical record, (e.g., nursing home record, doctor’s orders, progress notes, office records, and nursing notes), must be available upon request.
Utilization Guidelines
In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.
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.
