Behavioral Health Assessment/Intervention (96156-96171)

by  Find-A-Code™
Jan 1st, 2019 - Reviewed/Updated May 5th

Health behavior assessment and intervention services address psychological and behavioral factors affecting physical health conditions. The primary diagnosis is medical, with services focused on improving coping, adherence, and outcomes. Assessment evaluates responses to illness, coping, and motivation through interviews and observation. Interventions promote functional improvement, reduce barriers to recovery, and support coping, involving patients and/or families individually or in groups.

Beware: Diagnosis codes from Chapter 5. Mental, Behavioral and Neurodevelopmental disorders (F01-F99) should not be reported as the primary diagnosis code.

Documentation for all health behavior services (96156-96171) should include the following:

• Diagnosis: Report a covered non-psychiatric diagnosis code. Behavioral health diagnosis codes F01-F99 should not be used to report these services.
• Patient status: The patient must be alert, oriented, and have the ability to understand and respond meaningfully during the encounter. Be sure to include how these services impact the management of their condition(s) and activities of daily living.
• Barriers: Services must focus on the following areas:
  • Cognitive
  • Emotional
  • Social
  • Behavioral functioning
• Provider type: CPT and Medicare guidelines state that those who are allowed to use E/M and/or Preventive Medicine services codes should not use these codes. Therefore, the documentation needs to clearly identify the type of provider rendering these services. For Medicare, only a clinical psychologist is covered. Review payer policies to determine provider type requirements.
• Reasonable and necessary: Payer policies will generally outline what they consider to be reasonable and necessary. Where possible, be sure that documentation addresses why it meets their criteria.
• Patient compliance: How well is the patient complying with their medical treatment plan? How well do they adhere to the plan? What obstacles are preventing them from complying?

NON-COVERAGE: If documentation includes any of the following it may indicate that either different codes should be reported (e.g., psychotherapy, behavioral health integration) or they are not covered services (e.g., recreational services):

• Update/educate family on patient’s condition
• Educate staff on patient’s care plan or treatment planning
• Provide family psychotherapy or mediation
• Educate diabetic patients or family
• Deliver medical nutrition therapy
• Personal, social, recreational, and general support services
• Maintain the patient’s or family’s existing health and overall well-being

Assessment and Re-assessment

Documentation for both the assessment and re-assessment for behavioral health should include the following:

• Time: Even though code 96156 does not have a time component, from an audit perspective, it is recommended that this information be included in the documentation.
• Referral: Medicare and many other payers require a referral from another healthcare provider (e.g., physician, nurse practitioner, physician assistant) requesting these services to address patient barriers.
• Care coordination: There should be evidence of care coordination with the referring provider, primary care provider, and/or other agencies involved in the patient’s care.
• Evaluation: This is an evaluation of the patient’s response(s) to their condition(s). According to CPT guidelines, this includes their “outlook, coping strategies, motivation, and adherence to medical treatment.” Where possible, include evidence of the biopsychosocial factors which may be significantly affecting the treatment or medical management of their condition(s).
• Measurable Goals: The initial assessment will set individualized patient goals which will be evaluated and revised as needed during the re-assessment.

Initial Assessment

In addition to the previously discussed items, documentation should include ALL of the following components:

• Onset and history of diagnosis
• Rationale for assessment
• Assessment outcome
• Duration and frequency of interventions recommended

Re-assessment

Depending on individual payer policies, it is likely that the following documentation components are required:

• Date of change in psychological or medical status which justifies the need for re-evaluation of the patient’s capacity to understand and cooperate with the medical interventions necessary to their health and well being 
• Rationale for reassessment 
• Indication of precipitating event

Health Behavior Intervention (96158-96171)

Documentation of intervention services needs to include the following, where applicable:

• Time: These are timed services so start and stop times need to be part of the medical record. 
• Type of encounter: Was this an individual, group, or family encounter? Identify all individuals present.
• Compliance: Is there evidence of improved patient compliance with the treatment plan? 
• Responses: What are their responses to clinical intervention?
• Plan: Evidence of clearly addressing the patient’s intervention plan
• Frequency: Rationale provided for frequency and duration of service

Tips

• Be sure that it is clear that these services could not be reported with another type of service (e.g., medical nutrition therapy).
• Payers may have limitations on frequency of services (e.g., 12 hours regardless of the number of sessions) so be sure cumulative time is carefully monitored and documented.