Group 1 Codes:
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 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; reassessment
96152 Health and behavior intervention, each 15 minutes, face-to-face; individual
96153 Health and behavior intervention, each 15 minutes, face-to-face; group (2 or more patients)
96154 Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient present)
Group 2 Paragraph: The following CPT code is not covered by Medicare.
Group 2 Codes:
96155 Health and behavior intervention, each 15 minutes, face-to-face; family (without the patient present)
QUESTIONS AND ANSWERS
1 Q: If a Physician reports codes from the Health and Behavior Assessment/Intervention series using CPT 96150–96155 will he or she be reimbursed?
A: No. CPT 96150–96155 should only be reported by qualified nonphysician health care professionals. As indicated in the parenthetical note following the Health and Behavior Assessment/Intervention guidelines in the CPT book, Physicians performing health and behavior assessments/interventions should report the appropriate Evaluation and Management or Preventive Medicine service codes.
2 Q: What would be the appropriate CPT or HCPCS code for a registered dietitian to report for medical nutrition therapy services?
A: Registered dietitians should report specific CPT or HCPCS codes that accurately identify the service performed using CPT codes 97802–97804 and HCPCS codes G0270–G0271.
Coverage Indications, Limitations, and/or Medical Necessity
The Health and Behavioral Assessment, initial (CPT code 96150) and Reassessment (CPT code 96151), and Intervention services (CPT codes 96152-96153) may be considered reasonable and necessary for the patient who meets all of the following criteria:
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 evaluation or intervention to successfully manage his/her physical illness, and activities of daily living, and
The assessment is not duplicative of other provider assessments
In addition, for a reassessment to be considered reasonable and necessary, there must be documentation that there has been a sufficient change in the mental or medical status warranting re-evaluation of the patient's capacity to understand and cooperate with the medical interventions necessary to their health and well being.
Health and Behavioral Intervention (with the family and patient present) (CPT code 96154) is considered reasonable and necessary for the patient if the family representative directly participates in the overall care of the patient.
Health and Behavioral Assessment/Intervention will not be considered reasonable and necessary for the patient who:
Does not have an underlying physical illness or injury, or
For whom there is no documented indication that a biopsychosocial factor may be significantly affecting the treatment, or medical management of an illness or injury (i.e., screening medical patient for psychological problems), or
Does not have the capacity to understand and to respond meaningfully during the face to face encounter, because of:
Dementia that has produced a severe enough cognitive defect for the psychological intervention to be ineffective.
Severe and profound mental retardation
Persistent vegetative state/no discernible consciousness,
Impaired mental status, e.g.,
Disorientation to person, time, place, purpose, or
Inability to recall current season, location of own room, names and faces, or
Inability to recall that he or she is in a nursing home or skilled nursing facility, or
Does not require psychological support to successfully manage his/her physical illness through identification of the barriers to the management of physical disease and activities of daily living, or
For whom the conditions noted under the indications portion of this section are not met.
Because it does not represent a diagnostic or treatment service to the patient, there is no coverage for CPT code 96155.
Examples of Health and Behavioral Intervention services not considered reasonable and necessary and not covered are:
Provide family psychotherapy or mediation
Maintain the patient's or family's existing health and overall well-being
Provide personal, social, recreational, and general support services. Although such services may be valuable adjuncts to care, they are not medically necessary psychological interventions.
Individual social activities
Teaching social interaction skills
Socialization in a group setting
Vocational or religious advice
Tobacco or caffeine withdrawal support
Teaching the patient simple self-care
Weight loss management
Maintenance of behavioral logs
Health and Behavioral Assessment/Intervention (CPT codes 96150-96154) may only be performed by a Clinical Psychologist (CP-Specialty Code 68).
Biofeedback is coded as 90901 and will not be covered as a health and behavioral intervention.
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
999x Not Applicable
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
99999 Not Applicable