January 8, 2020 | By Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA
It is truly amazing to finally begin to see new reimbursement opportunities for services that providers have given for years without compensation. One such area is in a new code set this year for Behavior Assessment & Intervention. This code set offers a way for providers who are treating the “whole” patient and not just the presenting problem. The services are used on patients whose primary diagnosis is physical in nature which is being complicated by psychological concerns, behavior issues, emotional concerns, cognitive factors and interpersonal issues.
Currently, many specialists with patients who develop these issues out of a physical diagnosis have sent these patients for a consult to a mental health provider. These codes now allow for any provider to address the issues at hand and develop the proper interventions and not only treat the physical issue but these underlying issues as well. The addition of these services for 2020 in no way requires that the treating provider also treat the behavior concerns, but for those who wish to it does provide the means for reimbursement for the service provided. Of course, there will be patients who may demonstrate behavior concerns that exceed the treating provider’s expertise and then we would expect that the patient would be sent for mental health services.
There are two distinct services provided in this code set and they are- Assessment and Intervention. AMA CPT has provided Section Guidelines that define the differences in the two services, and they are:
Health behavior assessment: includes evaluation of the patient’s responses to disease, illness or injury, outlook, coping strategies, motivation, and adherence to medical treatment. Assessment is conducted through health-focused clinical interviews, observation, and clinical decision making.
Health behavior intervention: includes promotion of functional improvement, minimizing psychological and/or psychosocial barriers to recovery, and management of and improved coping with medical conditions. These services emphasize active patient/family engagement and involvement. These interventions may be provided individually, to a group (two or more patients), and/or to the family, with or without the patient present.
So, let’s paraphrase these statements into lay terms:
Assessment = evaluation of the patient status
Intervention = treatment of the behavioral concerns
Even with this brief introduction to this code set, I am sure you are already thinking of specialties and patient situations when this could be instrumental- oncology, cardiology, rheumatology, trauma- truthfully the list can go on. Now, we will look at what work is required to support these services.
Assessment FAQ
96156 Health behavior assessment. or re-assessment (ie. health-focused clinical interview, behavioral observations, clinical decision making)
- This service is provided one-on-one with a physician or QHP (qualified healthcare provider)
- The code is used for initial assessment as well as any re-assessments required
- This is NOT a time based service
- Documentation should include an assessment of the patient adjustments to the presenting problem and identify any behavioral issues that exist
Intervention FAQ
96158 – 96171 Health behavior intervention. individual. face-to-face- is the base description for each code. The difference amongst the codes exist on the length of the session and who is participating.
- Each base code is for the initial 30 minutes. AMA CPT provides a reminder in the section notes that 16 minutes must be met in order to report the base service code
- Add-on codes have been created to report each additional 15-minute increment of time. remember that when using an add-on code that the full 30 (not 16) minutes must first be met
- Codes were created to report either an individual session, a group session (no less than 2), family with the patient, and last family without the patient included
- Documentation expectations:
- Overview: A review of treatment progress, outlook/goals, understanding or lack of understanding their condition and treatment, and attitude toward the treatment and the care team members.
- Treatment: Services provided to the patient toward modifications of behavioral concerns
- Progress: QHP is expected to include documentation on the patient’s progress toward their treatment goals as well as any modifications needed
The assessment code will be used initially and on occasion, but the intervention codes may be used more frequently. Therefore, to make it easy, we created a clip and save chart below for you.
Educate your providers on these services, the documentation requirements, and the appropriate settings.
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Health Behavior Intervention Services- MUST be face-to-face |
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| Source | Time | Code | Reimbursement |
| Individual | 30 | 96158 | $68.00 |
| 45 | 96158 + 96159 | $93.00 | |
| Group (2+ Patients) | 30 | 96164 | $10.00 |
| 45 | 96164 + 96165 | $15.00 | |
| Family w/o Patient | 30 | 96167 | $73.00 |
| 45 | 96167 + 96168 | $99.00 | |
| Family w/Patient | 30 | 96170 | $83.00 |
| 45 | 96170 + 96171 | $113.00 | |
