documentation requirements for cpt code 96160

CPT codes, descriptions and other data only are copyright 2022 American Medical Association. As clinical or administrative codes change or system or policy requirements dictate, CR instructions are updated to ensure the systems are applying the most appropriate claims processing instructions applicable to the policy. CMS has defined "not usually self-administered" according to how the Medicare population as a whole uses the drug, not how an individual patient or physician may choose to use a particular drug. preparation of this material, or the analysis of information provided in the material. The code lists in the article help explain which services (procedures) the related LCD applies to, the diagnosis codes for which the service is covered, or for which the service is not considered reasonable and necessary and therefore not covered. contact your MAC for guidance. For example, Aetna clearly encourages and pays for depression screening reported with code 96127 and ICD-10 code Z13.89, Encounter for screening for other disorder. Cigna has a national policy that provides separate coverage of developmental screening (96110), brief behavioral health assessment (96127), and depression screening reported with HCPCS code G0444. Another option is to use the Download button at the top right of the document view pages (for certain document types). How Do 96160/96161 Differ From Other Screening and Assessment Codes? (96160/96161) Codes 99408/99409 cannot be reported for the same patient, on the same date of service, as Health Behavior Assessment . Modifier 33 may be required to indicate a service that may be preventive or diagnostic was provided as a preventive service. All documentation must be maintained in the patient's medical record and made available to the contractor upon request. For more information, visit Getting Paid for Screening and Assessment Services at www.aafp.org/fpm/2017/1100/fpm20171100p25.pdf and A Framework for Patient-Centered Health Risk Assessments at www.cdc.gov/policy/hst/HRA/FrameworkForHRA.pdf. recipient email address(es) you enter. CPT code 96160 allows allergists to get reimbursed when they make use of certain standardized asthma assessment instruments. If test is administered by physician, other qualified health care professional, or technician, do not report 96146. End Users do not act for or on behalf of the CMS. ). Because of the impact on the medical management of the patients disease, documentation must show evidence of coordination of care with the patients 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. However, code 96127 should be reported for both screening and follow-up of. Example: An 18-month-old established patient is seen for a well-child exam. However, code 96127 should be reported for both screening and follow-up of emotional and behavioral health conditions. This code is used when a healthcare provider administers a standardized questionnaire to a patient to help identify specific health risks, analyzes the results, assigns a score, and documents the findings. CPT 96161: This code is used for the administration of a caregiver-focused health risk assessment instrument, such as a depression inventory, for the benefit of the patient. Clarification was made to the Health and behavioral assessment and Health and behavioral intervention. CPT 96160 was added to the Current Procedural Terminology system on January 1, 2017. CMS and its products and services are The CPT guidelines for 96156-96161 provide an important reminder about how 96160/96161 differ from two other screening and assessment codes: 96110 (Developmental screening [eg, developmental milestone survey, speech and language delay screen] with scoring and documentation, per standardized instrument) and 96127 (Brief emotional/behavioral In addition, the physician must document that he or she reviewed the score in the context of the patient presentation and discussed the results with the patient/family as part of the related E/M service. Draft articles have document IDs that begin with "DA" (e.g., DA12345). Many payers and clearinghouses offer code edit simulators for use in determining whether codes for services such as screenings and assessments are bundled or separately paid. Only the preventive medicine E/M service code, reported with ICD-10 codes Z00.01, F32.1, and Z13.89, is reimbursed. Medicaid and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration Please contact your Medicare Administrative Contractor (MAC). A few payers do indicate that a report (separate from the E/M service documentation) is also required, so verify your payers' documentation requirements prior to providing these services. Use for both screening and follow-up of emotional and behavioral health conditions. Required fields are marked *. National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits do not bundle 96160 and 96161 into the office/outpatient evaluation and management (E/M) codes 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient ) or the preventive medicine E/M codes 99381-99396 (Initial/periodic comprehensive preventive medicine evaluation/reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new/established patient ), and no CPT regulations prohibit the services from being reported together. However, if the physician diagnoses depression, you may report it separately since the global package was valued for uncomplicated antepartum, delivery, and postpartum care. Enter the CPT/HCPCS code in the MCD Search and select your state from the drop down. Inpatient prolonged services codes 99356 and 99357 also . Medical records need not be submitted with the claim; however, the medical record, (e.g., nursing home record, doctors orders, progress notes, office records, and nursing notes), must be available upon request. All rights reserved. 27) Encounter for routine child health exam with abnormal findings Depression Screening (pg. In other words, HRAs identify patients modifiable health risks, which then allows a pediatrician to then provide follow-up behavior change interventions and improve health outcomes, according to the Centers for Disease Control and Prevention (CDC) (Source: https://www.cdc.gov/policy/hst/HRA/FrameworkForHRA.pdf). Enter the code you're looking for in the "Enter keyword, code, or document ID" box. Any follow-up appointments or referrals made based on the assessment results. that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes. Because health risk assessments (HRAs) appear so similar to other assessment services, using the HRA codes can be a real gamble. HCPCS modifiers such as modifier EP may be required by Medicaid plans to indicate a service was provided as part of a Medicaid early periodic screening diagnosis and treatment program, or they may require other state-defined modifiers. of every MCD page. Copyright 2017 by the American Academy of Family Physicians. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, AMA Plaza 330 N. Wabash Ave., Suite 39300, Chicago, IL 60611-5885. When 96160 and 96161 are column 1 codes to 96127 and 96110, NCCI considers the column 2 codes as components of the HRA services, though as NCCI assigns the PTP pairs modifier indicators of 1, the edits may be overridden with an NCCI-associated modifier when appropriate. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. See the CMS . When billing for non-covered services, use the appropriate modifier. The CPT Codes discussed in this Billing and Coding Article are used to report the services provided during testing of the cognitive function of the central nervous system. Several scenarios require use of a modifier when billing for screening and assessment services, including the following: Modifier 25 may be required to indicate a significant, separately identifiable preventive or other E/M service was provided on the same date. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials. The submitted medical record must support the use of the selected ICD-10-CM code(s). recommending their use. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. CPT code 96150 : Health and behavior initial assessment, each 15 minutes face-to-face with the patient CPT code 96151 : Health and behavior re-assessment, each 15 minutes face-to-face with the patient Deleted H&B Assessment Services (Effective 1/1/2020) 6 Complete absence of all Revenue Codes indicates 2. Code 99483 provides reimbursement to physicians and other eligible billing practitioners for a comprehensive clinical visit that results in a written care plan . The list of results will include documents which contain the code you entered. Report code 96161 for a health risk assessment when focused on care-giver risk that may impact the patient's health (e.g., postpartum depression). The official description of CPT code 96160 is: Administration of patient-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation, per standardized instrument.. So, 96110 and 96127 are used whenever your provider is assessing a patients psychological and neuropsychological condition, such as a patients memory, language, visual motor responses, and abstract reasoning/ problem-solving abilities, whereas 96160/96161 are used whenever your provider is assessing how a psychological condition is impacting a patients health condition (96160) or how the patients caregivers psychological condition may affect the caregivers ability to care for the patient (96161). Documentation should include the date, patient's name, name and relationship of the informant (when information is provided by someone other than the patient), name of the instrument, score, and name and credentials of the individual administering/scoring the instrument. In most cases, modifiers will override the edits when clinically appropriate. Please do not use this feature to contact CMS. The healthcare provider determines the appropriateness of administering a health risk assessment instrument based on the patients medical history, current health status, and potential risk factors. Specifically, CPT code 96160 describes the administration of patient-focused health risk assessment instruments with scoring and documentation, per standardized instrument. The following CPT codes are not applicable for developmental delay screening or testing: 96160, 96161, 99411, 99412, 99429. These patients may have a family history of certain diseases, exhibit risk factors such as obesity or smoking, or have a history of exposure to environmental hazards. Medicare contractors are required to develop and disseminate Articles. All you have to do is learn the answers to these frequently asked questions. Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, Instrument-based assessment of the patient's risk for certain health conditions, behaviors that may negatively impact health, and pros and cons for initiating behavior change, Mini Nutritional Assessment - Short Form, Acute Concussion Evaluation, Alcohol Use Disorders Identification Test, CRAFFT (Care, Relax, Alone, Forget, Friends, Trouble), and HEE-ADSSS (Home, Education, Eating, Activities, Drugs and Alcohol, Suicide and Depression, Sexuality and Safety). All Rights Reserved (or such other date of publication of CPT). If you need an accommodation or require documents in another format, please call 1-800-562- 3022. Be aware that some payers will only reimburse psychologists and psychiatrists for treating depression. 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. 96160 96161 CPT 96160, Under Health Behavior Assessment and Intervention Procedures The Current Procedural Terminology (CPT ) code 96160 as maintained by American Medical Association, is a medical procedural code under the range - Health Behavior Assessment and Intervention Procedures. Payer guidance for reporting postpartum depression screening also varies. Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt. Alcohol and Substance Abuse Screening and Brief Intervention (i.e., CRAFFT) pg. or call toll-free from U.S.: (800) 762-2264 or (240) 547-2156 Though screening and assessment services require verification of benefits and of coding and documentation requirements, these services may be beneficial to both the patient and the practice. Are HRAs Bundled Into E/Ms or Other Services? For example, the assessment might be done on a new mother to see if there is any problem, such as postpartum depression, that could affect the care of the patient, Bucknam adds. an effective method to share Articles that Medicare contractors develop. Instrument-based assessment of the caregiver's risk for certain health conditions that may impact his or her ability to care for the patient, Safe Environment for Every Kid, Caregiver Strain Index, and Edinburgh Postnatal Depression Scale (administered for benefit of the child). Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. The patient expresses a feeling of hopelessness related to relationships lost during opioid use and sexuality issues. For instance, one plan in Tennessee has paid. If you are experiencing any technical issues related to the search, selecting the 'OK' button to reset the search data should resolve your issues. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. Save my name, email, and website in this browser for the next time I comment. (See last page for instructions. Unless specified in the article, services reported under other The physician reports code 99392 for the preventive service and two units of code 96110 for the administration of the structured screening instruments. The HRA codes 96160 (Administration of patient-focused health risk assessment instrument [eg, health hazard appraisal] with scoring and documentation, per standardized instrument) and 96161 (Administration of caregiver-focused health risk assessment instrument [eg, depression inventory] for the benefit of the patient, with scoring and documentation, per standardized instrument) like all the health behavior assessment and intervention codes (96156-96161) are used to identify and address the psychological, behavioral, emotional, cognitive, and interpersonal factors important to the assessment, treatment, or management of physical health problems, according to CPT guidelines. The CMS.gov Web site currently does not fully support browsers with A patient with a history of smoking completes a lung cancer risk assessment instrument under the guidance of their healthcare provider. Article document IDs begin with the letter "A" (e.g., A12345). To support a claim for CPT 96160, the following information should be documented in the patients medical record: When billing for CPT code 96160, it is important to remember that the code includes the administration of the standardized questionnaire, scoring, and documentation. If you would like to extend your session, you may select the Continue Button. Sign up to get the latest information about your choice of CMS topics in your inbox. CPT codes 96150 - 96154 are to be billed as one service for each 15 minute of face-to-face contact with the beneficiary(s). Code 96161, on the other hand, assesses a caregiver for the patient, not the patient him/herself, when the caregiver may have a condition that is affecting the patient. How Do 96160/96161 Differ From Other Screening and Assessment Codes? Therefore, if a drug is self-administered by more than 50 percent of Medicare beneficiaries, the drug is excluded from coverage" and the MAC will make no payment for the drug. CPT Code 96160 may not be used to claim a stand-alone administration of a CRAFFT (CPT Code 96127) brief screen. Depression screening, reported with 96127, is typically a covered preventive service for adolescents age 12 to 18 and is a quality measure in many pediatric quality initiatives. Before sharing sensitive information, make sure you're on a federal government site. 96160 Administration of patient-focused health risk assessment instrument (e.g., . When more than four CPT codes 96150 are submitted by a provider/group the additional services will be denied. But you can quickly learn to use screening and assessment codes effectively and accurately. CPT codes 96158, 96164, and 96167 should not be reported for less than 16 minutes of service. Recent changes to CPT codes for structured screenings and brief assessments have led some payers to expand coverage for these services. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. If a redetermination is requested, documentation showing the "CPT Copyright American Medical Association. American College of Obstetricians and Gynecologists Per CPT, standardized instruments are validated tests that are administered and scored in a consistent or standard manner consistent with their validation. For 96160, that would include such tests as the Mini Nutritional Assessment-Short Form; Sport Concussion Assessment Tool (SCAT 5-); Alcohol Use Disorders Identification Test; Care, Relax, Alone, Forget, Friends, Trouble (CRAFFT); and Home, Education, Eating, Activities, Drugs and Alcohol, Suicide and Depression Sexuality and Safety (HEEADSSS), while standardized tests appropriate for 96161 include the Safe Environment for Every Kid; Caregiver Strain Index; and Edinburgh Postnatal Depression Scale, according to Cindy Hughes, CPC, CFPC, consulting editor of Cindy Hughes Consulting in El Dorado, Kansas. The document is broken into multiple sections. Reproduced with permission. Use for developmental and autism screening. The 96160 CPT code procedure involves the following steps: Patients eligible to receive CPT code 96160 services are those who may be at risk for developing specific health issues or conditions. If you are looking for a specific code, use your browser's Find function (Ctrl-F) to quickly locate the code in the article. In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice. The healthcare provider discusses the results with the patient and provides recommendations for managing or reducing identified health risks. 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. Simply put, the two differ over who is being assessed. All Rights Reserved. Sometimes, a large group can make scrolling thru a document unwieldy. Heres your guide to risk-free screening and assessment coding. The physician provides the age- and gender-appropriate history and examination and briefly discusses the positive depression screening result with the patient. Health and behavioral assessment is an evaluation of psychological, behavioral, emotional, cognitive and social factors that affect the patients response. If you need more information on coverage, contact the Medicare Administrative Contractor (MAC) who published the document. The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administration of the Medicare, Please refer to the Local Coverage Article: Billing and Coding: Health and Behavior Assessment/Intervention (A57754) for documentation requirements that apply to the reasonable and necessary provisions outlined in this LCD. LCD revised to add CPT/HCPCS codes 96160, 96161, and G0505. MACs can be found in the MAC Contacts Report. This code should be used for each standardized survey questionnaire administered, as long as the criteria are established and agreed upon by a group of experts. *7. You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Are HRAs Bundled Into E/Ms or Other Services? To report, see 96127, 96136, 96137, 96138, 96139. Please Note: For Durable Medical Equipment (DME) MACs only, CPT/HCPCS codes remain located in LCDs. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. The page could not be loaded. The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. 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. For additional quantities, please contact [emailprotected] It is conducted through health focused interviews, observations, and clinical decision making. Revision Number: 1 Publication: December 2019 Connection LCR B2020-001. Be sure that your billing staff is aware of National Correct Coding Initiative and other payer edits that may bundle or limit the units of service for screening and assessment codes. Refer to the LCD for reasonable and necessary requirements and limitations. Instructions for enabling "JavaScript" can be found here. If that doesnt work please contact, Technical issues include things such as a link is broken, a report fails to run, a page is not displaying correctly, a search is taking an unexpectedly long time to complete. When reporting CPT codes 96159, 96165, and 96168, the quantity billed should reflect 1 unit for each 15 minutes. Code 96160 is for the patient, who may have risks that impact their health but that have not yet been diagnosed, says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington. If you're not coding and billing for these services, you might be leaving money on the table. Diagnosis code Z00.129, Encounter for routine child health examination without abnormal findings, is linked to each service reported as this code includes an encounter for developmental screening. The HRA codes are subject to PTP edits when reported with the other screening and assessment codes, however. CPT 96150: This code is used for an initial health and behavior assessment conducted by a healthcare professional. A healthcare provider administers a skin cancer risk assessment questionnaire to a patient with a history of sunburns and tanning bed use. 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. Was your Medicare claim denied? This test is performed using an electronic platform, such as a computer, and the results of the test are automatically generated. Both 96110 and 96127 reside in the central nervous system assessments/tests code group (96105-96146) and are used to report the services provided during testing of the central nervous system functions, per CPT. Procedure Coding: Get the Answers to Your Frequently Asked HRA Questions, Get the Answers to Your Frequently Asked HRA Questions, Simply put, the two differ over who is being assessed. Because health risk assessments (HRAs) appear [], Check Your Answers to Our Mental Health Coding Quiz, Time to find out if youre a Chapter 5 ace. Some articles contain a large number of codes. CPT 96138: This code is used for the administration and scoring of psychological or neuropsychological tests by a technician. Review the article, in particular the Coding Information section. ICD-10-CM Codes that Support Medical Necessity, ICD-10-CM Codes that DO NOT Support Medical Necessity, L33834 - Health and Behavior Assessment/Intervention, HEALTH BEHAVIOR ASSESSMENT, OR RE-ASSESSMENT (IE, HEALTH-FOCUSED CLINICAL INTERVIEW, BEHAVIORAL OBSERVATIONS, CLINICAL DECISION MAKING), HEALTH BEHAVIOR INTERVENTION, INDIVIDUAL, FACE-TO-FACE; INITIAL 30 MINUTES, HEALTH BEHAVIOR INTERVENTION, INDIVIDUAL, FACE-TO-FACE; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE), ADMINISTRATION OF PATIENT-FOCUSED HEALTH RISK ASSESSMENT INSTRUMENT (EG, HEALTH HAZARD APPRAISAL) WITH SCORING AND DOCUMENTATION, PER STANDARDIZED INSTRUMENT, ADMINISTRATION OF CAREGIVER-FOCUSED HEALTH RISK ASSESSMENT INSTRUMENT (EG, DEPRESSION INVENTORY) FOR THE BENEFIT OF THE PATIENT, WITH SCORING AND DOCUMENTATION, PER STANDARDIZED INSTRUMENT, HEALTH BEHAVIOR INTERVENTION, GROUP (2 OR MORE PATIENTS), FACE-TO-FACE; INITIAL 30 MINUTES, HEALTH BEHAVIOR INTERVENTION, GROUP (2 OR MORE PATIENTS), FACE-TO-FACE; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE), HEALTH BEHAVIOR INTERVENTION, FAMILY (WITH THE PATIENT PRESENT), FACE-TO-FACE; INITIAL 30 MINUTES, HEALTH BEHAVIOR INTERVENTION, FAMILY (WITH THE PATIENT PRESENT), FACE-TO-FACE; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE), Some older versions have been archived. What Counts as a Standardized Instrument? Via Non-Standardized Instrument or Assessment If SDOH risk factors are determined by use of a non-standardized instrument or assessment, CPT codes 96160 or 96161 cannot be reported. Your information could include a keyword or topic you're interested in; a Local Coverage Determination (LCD) policy or Article ID; or a CPT/HCPCS procedure/billing code or an ICD-10-CM diagnosis code. See permissionsforcopyrightquestions and/or permission requests. American Hospital Association ("AHA"), https://www.cdc.gov/policy/hst/HRA/FrameworkForHRA.pdf. Documentation Requirements. This email will be sent from you to the . For example, the assessment might be done on a new mother to see if there is any problem, such as postpartum depression, that could affect the care of the patient, Bucknam adds.

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