Monday, December 1, 2008

Behavioral health CPT codes for patients with a physical diagnosis

There are six reimbursement codes for health and behavior assessment and intervention. These codes apply to behavioral, social, and psychophysiological procedures for the prevention, treatment or management of physical health problems.

The health and behavior assessment and intervention codes

96150 – the initial assessment of the patient to determine the biological, psychological, and social factors affecting the patient’s physical health and any treatment problems.

96151 – a re-assessment of the patient to evaluate the patient’s condition and determine the need for further treatment. A re-assessment may be performed by a clinician other than the one who conducted the patient’s initial assessment.

96152 – the intervention service provided to an individual to modify the psychological, behavioral, cognitive, and social factors affecting the patient’s physical health and well being. Examples include increasing the patient’s awareness about his or her disease and using cognitive and behavioral approaches to initiate physician prescribed diet and exercise regimens.

96153 – the intervention service provided to a group. An example is a smoking cessation program that includes educational information, cognitive-behavioral treatment and social support. Group sessions typically last for 90 minutes and involve 8 to 10 patients.

96154 – the intervention service provided to a family with the patient present. For example, a psychologist could use relaxation techniques with both a diabetic child and his or her parents to reduce the child’s fear of receiving injections and the parents’ tension when administering the injections.

96155 – the intervention service provided to a family without the patient present. An example would be working with parents and siblings to shape the diabetic child’s behavior, such as praising successful diabetes management behaviors and ignoring disruptive tactics.

How these services differ from psychotherapy

Until now, almost all intervention codes used by psychologists involved psychotherapy and required a mental health diagnosis, such as under the DSM-IV. In contrast, health and behavior assessment and intervention services focus on patients whose primary diagnosis is physical in nature.

The codes capture services addressing a wide range of physical health issues, such as patient adherence to medical treatment, symptom management, health-promoting behaviors, health-related risk-taking behaviors, and overall adjustment to physical illness. In almost all of these cases a physician will already have diagnosed the patient’s physical health problem.

If a mental health clinician is treating a patient with both a physical and mental illness he or she must pay careful attention to how each service is billed. The health and behavior codes cannot be used for psychotherapy services addressing the patient’s mental health diagnosis nor can they be billed on the same day as a psychiatric CPT code. The clinician must report the predominant service performed.

Use of the codes will enable reimbursement for the delivery of psychological services for an individual whose problem is a physical illness and does not have a mental health diagnosis. Since these codes are new, reimbursement rates from the private sector have not been determined. However, it is important that psychologists begin to use these codes now to accurately capture the services provided.

New codes to be paid with physical health dollars in Medicare

When providing outpatient care to Medicare beneficiaries, services for these patients will be reimbursed at a higher rate than psychotherapy because under current Federal regulations, the outpatient mental health treatment limitation does not apply to these new services (it only applies to services provided to patients with a mental, psychoneurotic, or personality disorder identified by an ICD-9 CM diagnosis code between 290 and 319). For example, Medicare would reduce the approved amount of a 45-minute outpatient psychotherapy session by 62.5% and then reimburse 80% of the remainder, resulting in a payment of approximately $48. In contrast, Medicare would reimburse a 45-minute outpatient health and behavior intervention for an individual at 80% of the approved amount, or approximately $59.

Federal reimbursement for the health and behavior assessment and intervention codes will come out of funding for medical rather than psychiatric services and will not draw from limited mental health dollars. For private third party insurance we expect these services to be treated under the physical illness benefits of a plan and thus not be subjected to the higher outpatient consumer co-payment found in Medicare or relegated to behavioral health “carve out” provisions.

What non-physician practitioners are eligible for Medicare Part B for reimbursement?

Non-physician practitioners who are authorized under Medicare Part B programs to furnish mental health services include clinical psychologists, clinical social workers, nurse practitioners, clinical nurse specialists, and physician assistants. Medicare does not pay marriage and family therapists or licensed professional counselors for their mental health services.


No comments: