For additional information, contact:
APA Office of Health Care Finance
OHCF@apa.org
2020 Health Behavior Assessment and Intervention
Billing and Coding Guide
EXECUTIVE SUMMARY
Effective January 1, 2020, Current Procedural Terminology
(CPT®) codes 96150–96155 were deleted and a new code set
was implemented to report Health Behavior Assessment and
Intervention (HBAI) services. APA Services, Inc. developed this
guide to provide an explanation of the extensive changes as well
as describe the structure, function, and utilization of the new
code set established through APA’s collaborative work with
the American Medical Association (AMA) and the Centers for
Medicare and Medicaid Services (CMS).
The information contained in each of the guide’s sections is
provided to the right. APA encourages payers and providers to
utilize the guide to navigate the new landscape of health behavior assessment and intervention services, and to become familiar with the coding guidelines and payment policies associated
with these procedures.
Please direct any questions about this guide to APA’s Office
of Health Care Finance at OHCF@apa.org and the appropriate
APA Services expert will contact you. Additional APA Services’
resources are publicly available on APA’s website (https://
www.apaservices.org/practice/reimbursement/health-codes/
health-behavior).
© 2019 APA Services Inc.
SECTIONS
• Coverage Indications, Limitations, and Medical Necessity:
This section provides descriptions of the assessment and treatment services; specifics on determining medical necessity
(pages 3-5); and limitations of coverage (pages 5-6).
• Coding Information: This section contains a complete listing
and description of the new health behavior CPT® codes effective January 1, 2020 (pages 6-7).
• General Information: This section describes the documentation elements that are typically necessary to include in the
patient record to support use of the codes as well as coding
guidelines and instruction for proper reporting (pages 7-9).
• Utilization Guidelines: This section provides instructions to
assess coverage provisions and appropriateness of services
provided to a patient(s) and/or their family. The instructions
are intended to improve quality and efficiency of care, reduce
unnecessary and/or inappropriate services, and manage the
cost of health care benefits (page 9).
• Sources of Information: This section lists the scientific
evidence and educational resources to support the contents
of this guide (pages 9-11).
CPT Copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.
For additional information, contact:
APA Office of Health Care Finance
OHCF@apa.org
2020 Health Behavior Assessment and Intervention
Billing and Coding Guide
The initial development of health behavior services began in 1998
to satisfy the need for psychological assessment and intervention
services for patients who presented with a known or established
medical illness. These services were developed to assess how
the medical illness was affecting the patient’s physical health
and well-being and address any identified impact by modifying
the associated psychological, behavioral, emotional, cognitive,
and social factors (CPT Assistant, March 2002). As a result, a
CPT codes 96150–96155 were implemented in 2002 and health
behavior service began to be more widely provided.
Over the past two decades, there has been a significant increase
in the development and adaptation of evidence-based techniques
to address psychological factors impacting physical illness (Roditi
et al., 2011; Richards et al., 2018; Wysocki et al., 2006; Wilfley et
al., 2018). Treatment strategies have evolved from the general
application of behavioral expertise to physical health conditions
to the application of specific psychological principles in the global
treatment of physical health conditions. Interventions commonly
used include (but are not limited to) cognitive restructuring, operant behavior therapy and contingency management, stimulus
control, graded activation and behavioral activation, coping skills
training, problem solving training, functional and structural family
therapy, family communication training, relaxation skills training,
and motivational interviewing. These changes have resulted in
greater specialization in training, as well as the development of
treatment guidelines for psychologists providing these services in
both the primary care (McDaniel et al., 2014) and specialty care
settings for chronic non-communicable diseases such as cardiovascular disease (Bosworth et al., 2018), obesity (APA, 2018),
pain (Wandner et al., 2019), diabetes (ADA, 2018), traumatic
brain injury (Ponsford et al., 2016), stroke (Hildebrand, 2015),
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spinal cord injury (Russell et al., 2016), amputations (Highsmith
et al., 2016) and bariatrics (Sogg et al., 2016).
As clinician and medical condition specification continued to
develop, health behavior services were used with increasing
frequency in outpatient settings for both primary and specialty
care, a finding that is supported by Medicare claims data (2002–
2017). For example, in 2002, only 9% of the claims for the Health
and Behavior Assessment service (CPT code 96150) were in
General Outpatient compared to 24% in 2017. The same time
period saw a 20% increase in the use of the Health and Behavior Individual Treatment service (CPT code 96152) in General
Outpatient and 10% increase in the use of this code in Physician
Offices (AMA, 2019). The higher frequency of use of the codes
in outpatient settings can be attributed to the increased focus
on integrating behavioral health services into both primary and
specialty care settings (APA, 2016; SAMSA-HRSA, 2018).
The population of patients with chronic noncommunicable
diseases like the ones listed above has also grown since the code
set was initially developed resulting in a significant increase in
complexity and cost of care (The US Burden of Disease Collaborators, 2018). For example, it is estimated that just 5% of
patients account for 50% of health care costs. The National
Academy of Medicine identified four core groups of high cost
patients: 1. children with severe disabilities; 2. adults with significant chronic illness (two or more complex conditions, and one
complex plus one to five noncomplex conditions); 3. frail elderly;
and 4. disabled patients under 65. Within these high-cost groups,
there is a subgroup of high needs patients defined as complex
medical high cost patients. These individuals typically have functional limitations and their circumstances often require behavioral services (Hayes et al., 2016; Long et al., 2017; Nahin, 2015).
CPT Copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.
Effective and efficient treatment of these high-cost and highneed patients necessitates health behavior assessment to evaluate the behavioral and psychological variables contributing to
poor health care monitoring, adherence, and health-promoting
behaviors to determine specific behavioral interventions and
other service needs.
Health behavior intervention includes promotion of functional
improvement, minimization of psychological or psychosocial
barriers to recovery, and management of and improved coping
with medical conditions. These services emphasize active
patient/family engagement and involvement (AMA, 2020).
As the types and severity of these conditions have also evolved,
there is a greater need for inclusion of health behavior services
in patient treatment plans. In fact, the six risk factors contributing to over a third of all health care costs: tobacco use, poor diet,
substance abuse, high Body Mass Index, high systolic blood pressure, and high resting glucose levels (The US Burden of Disease
Collaborators, 2018) all have clear behavioral determinants that
can be effectively addressed by HBAI services.
Health behavior assessment and re-assessment (CPT code
96156) consist of assessing multiple domains and their degree
of impact, which can include but are not limited to:
Given how health behavior services have dramatically changed
over time, especially in areas of provider technique and knowledge, patient population, and the health care settings in which
they are offered, APA worked in collaboration with the AMA and
CMS to establish the 2020 Health Behavior Assessment and
Intervention (HBAI) code set. This new/revised family of codes
more accurately reflect current clinical practice, providing greater
focus on psychological and/or psychosocial factors in health as
well as the increased role these services have in interdisciplinary
care, particularly in primary, specialty care, post-acute, rehabilitation, and skilled nursing facility settings.
• Health beliefs, perception, and outlook
COVERAGE INDICATIONS, LIMITATIONS, AND
MEDICAL NECESSITY
• Sleep, diet, physical activity, and other health risk behaviors
Health Behavior Assessment and Intervention (HBAI) services
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. The patient’s primary diagnosis is physical in nature
and the focus of the assessment and intervention is on factors
complicating medical conditions and treatments. These codes
describe assessments and interventions to improve the patient’s
health and well-being by utilizing psychological and/or psychosocial interventions by a qualified health provider designed to
ameliorate specific disease-related problems.
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.
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Health Behavior Assessment or Re-Assessment
• Relevant medical history
• Adjustment to the medical illness or injury
• Psychological and environmental factors affecting management of the medical condition
• Understanding of treatment plan, benefits and risks of
procedures
• Health care decision-making skills
• Coping strategies, patient strengths
• Motivation and self-efficacy beliefs
• Treatment adherence and expectations
• Daily activities, level of behavioral activation, and functional
impairment
• Mental health and substance use (including tobacco and alcohol use)—current and past
• Social support, family and interpersonal relations
• Academic and vocational histories
• Mood
• Quality of life
Components of Health Behavior Assessment and/or
Re-Assessment
Three required elements that must be performed and documented in order to report CPT code 96156:
i. Health-focused clinical interview: Depending on the nature
of the referral question, the qualified health care professional
(QHP) conducts the face-to-face health-focused clinical interview with the patient that may assess multiple domains as
outlined above. Collateral interviews are conducted as appropriate. When it precedes a health behavior intervention, the
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2
clinical assessment would determine the type(s) of intervention that would best benefit the patient.
ii. Behavioral observations: The QHP evaluates how the patient
is responding throughout the health-focused clinical interview
through direct behavioral observation. There will be variability across patients depending on a wide variety of factors
including patient complexity, comorbidities, severity of medical condition(s), and other factors that drive the clinical decision-making process.
iii. Clinical decision making: The QHP integrates information
learned prior to the interview (record review, discussions
with other health care providers) with information gained
during the health-focused clinical interview and behavior
observations to formulate the case conceptualization/clinical impressions, established or suspected medical diagnoses,
any additional diagnoses determined by the QHP, and treatment recommendations.
Medical Necessity: Health Behavior Assessment or
Re-Assessment
The Health Behavioral Assessment or Re-Assessment service
may be considered reasonable and necessary for the patient who
meets all the following criteria:
• The patient has an established or suspected underlying physical illness or injury and the purpose of the assessment or
re-assessment is not primarily for the diagnosis or treatment
of mental illness;
• There are indications that psychological, behavioral, and/or
psychosocial factors may be affecting the treatment or medical management of an illness or an injury;
• The patient is alert, oriented, and has the capacity to understand and to respond meaningfully during the face-to-face
encounter;
• The patient has an established or suspected underlying physical illness or injury needing a health behavior evaluation and/
or intervention to successfully manage their physical illness
and activities of daily living.
• The patient can be referred from a medical or mental health
care provider, or self-referred to seek assistance in addressing
the role of psychological and/or behavioral factors affecting
an underlying physical health condition.
Re-Assessment
In addition to meeting all the criteria stated above, medical necessity for re-assessment must be further established through documentation of one of the following:
• Change in the mental or medical status warranting
re-evaluation;
• Specific concern from the primary medical provider or member
of medical team;
• Need for re-assessment as part of the standard of care;
• Change in providers; or
• At least a 6-month period of time has elapsed since the last
assessment.
Health behavior assessment or re-assessment is considered
medically necessary for one or more of the following indications,
where there is a need to:
1. Assess psychological and/or behavioral factors that impact
the management of a patient’s acute or chronic medical condition (e.g., assessment of stress and its impact on diabetes
management); or
2. Assess patient’s responses to disease, illness or injury, outlook
(e.g. health beliefs and attitudes), coping strategies, motivation, and adherence to medical treatment; or
3. Assess behavioral and contextual factors that impact disease
management in scenarios that include, but are not limited to:
a. pre-surgical evaluation to identify psychological factors
that may potentially affect or complicate the outcome of
surgical procedures and/or aftercare (e.g., spinal surgery,
bariatric surgery, implantable therapies, organ transplant);
b. assessment of emotional/personality factors impacting
physical disease management and ability to comply with
and/or benefit from medical interventions;
c. assessment of psychosocial and/or environmental factors
that can impact a patient’s ability to comply with and/or
benefit from medical interventions; or
4. Assess psychological barriers and strengths to aid in treatment
planning, including but not limited to:
a. the selection of treatment options when several evidencebased approaches may be indicated;
b. determining treatment prognosis and outcomes;
c. identifying reasons for poor response to medical treatment; or
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3
5. Assess and monitor psychological factors and impact on medical condition and management over time (repeated assessments); or
• Psychoeducation related to the psychological, behavioral, and/
or psychosocial aspects of the patient’s illness or presenting
problem
6. Assess health related risk behaviors (e.g., sleep, diet, physical
activity, tobacco use) and their impact on the medical condition and management.
• Stimulus control
Health Behavior Intervention
Intervention services may be provided to:
• An individual (and is billed with CPT codes 96158, +96159);
• A group of two or more patients (and is billed with CPT codes
96164, +96165 for each individual patient in the group);
• A family, with the patient present (and is billed with CPT codes
96167, +96168); or
• A family, or without the patient present (and is billed with CPT
codes 96170, +96171)
› Note: APA firmly believes that Health Behavior Family Intervention without the patient present (96170/+96171) should be a reimbursable service
as it benefits the patient’s medical treatment and management; however,
as coverage varies, providers should check with their insurance carrier
for verification of coverage.
Family intervention services, whether the patient is or is not present, involves face-to-face interaction with “family representative(s)” (see definition in the Addendum B) (CMS, 2018).
Health behavior intervention includes promotion of functional
improvement, minimization of psychological or psychosocial
barriers to recovery, and management of and improved coping
with medical conditions. These services emphasize active
patient/family engagement and involvement.
Evidence-based health behavior interventions address psychological/behavioral factors that can be influencing a person’s
medical condition and consist of various types of treatment interventions, including but not limited to:
• Motivational interviewing
• Problem solving training
• Coping skills training
• Relaxation techniques and skills training
• Cognitive restructuring
• Emotional awareness and management
• Operant behavior therapy and contingency management
• Graded activation, behavioral activation, and pacing
techniques
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• Functional and structural family treatment
• Communication skills training
• Mindfulness techniques
Medical Necessity: Health Behavior Intervention
Services
The health behavioral intervention services (CPT codes
96158/+96159, 96164/+96165, 96167/+96168, 96170/+96171)
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
• Specific psychological intervention(s) and patient outcome
goal(s) have been clearly identified and documented
• Psychological intervention is necessary to address:
› Non-adherence with the medical treatment plan, or
› The psychological and/or psychosocial factors associated
with a newly diagnosed physical illness, or an exacerbation
of an established physical illness, when such factors affect:
–
–
–
–
symptom management and expression
health-promoting behaviors
health-related risk-taking behaviors
overall adjustment to medical illness.
• There are indications that psychological, behavioral, and/or
psychosocial factors may be affecting the treatment or medical management of an illness or an injury
• The patient is alert, oriented and has the capacity to understand
and to respond meaningfully during the intervention service
In addition to the criteria above, family intervention with patient
present (CPT codes 96167/+96168) and without patient present (CPT codes 96170/+96171) is considered reasonable and
necessary for the patient who meets all of the following criteria:
• The “family representative” (see definition in the Addendum
B) directly participates in the overall care of the patient, and
• The psychological intervention with the patient and family
is necessary to address psychological and/or psychosocial
factors that affect adherence with the plan of care, symptom
management, health-promoting behaviors, health-related
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4
risk-taking behaviors, and overall adjustment to medical illness.
Health behavior intervention services are considered
medically necessary when one or more of the
following needs are present:
meaningfully during the face-to-face encounter for reasons
such as, but not limited to:
› Cognitive status that indicates inability to actively participate and benefit from services;
1. Modify and manage psychological and behavioral factors
that are impacting the management of a patient’s acute or
chronic medical condition (e.g., improve stress management
to improve diabetes management); or
› Severe dementia that has produced a severe enough
cognitive defect for the psychological intervention to be
ineffective;
2. Modify and/or improve a patient’s cognitive or emotional
responses to disease, illness or injury, outlook, coping strategies, motivation, and adherence to medical treatment through
the on-going maintenance or improvements resulting from
evidence-based treatments; or
› Persistent inability to engage in meaningful interpersonal
interactions including inability to respond to cues and
directions.
3. Modify and/or improve psychological and/or behavioral
factors that impact disease management in scenarios that
include but are not limited to:
a. Psychological factors affecting or complicating the
outcome of surgical procedures and/or aftercare (e.g.,
spinal surgery, bariatric surgery, implantable therapies);
b. The emotional/personality impacts on physical disease
management and/or the ability to comply with and benefit
from medical interventions; or
4. Modify and/or improve a patient’s adherence to medical treatment and/or health risk-related behaviors; or
5. Modify and/or improve a patient’s engagement in self-management and participation in treatment; or
6. Modify and/or improve a patient’s understanding of the medical condition, its treatment, and the psychological, behavioral,
emotional, cognitive, or social factors related to the prevention,
treatment or management of the medical condition.
Limitations of Coverage
Health behavior assessment and intervention services will not be
considered reasonable and necessary for the patient with any of
or all the following criteria:
• Does not have a suspected or established underlying physical
illness or injury; or
• For whom there is no indication that psychological and/or
psychosocial factors 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
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› Severe or profound intellectual disability;
The following would not be considered medically
necessary if provided as the primary health behavior
intervention service:
• Updating or educating the family about the patient’s condition
• Educating family members who do not meet the definition
of “family representative” (see definition in the Addendum B),
and other members of the treatment team (e.g., health aides,
nurses, physical or occupational therapists, home health aides,
personal care attendants, and co-workers) about the patient’s
care plan.
• Treatment-planning with staff
• Mediating between family members or providing family
psychotherapy
• Education that does not include the psychological, behavioral, and/or psychosocial aspects of the patient’s illness or
presenting problem
• Delivering Medical Nutrition Therapy (i.e., CPT codes 97802;
Medical nutrition therapy; initial assessment and intervention,
individual, face-to-face with the patient, each 15 minutes, 97803;
Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes, and 97804;
Medical nutrition therapy; group (2 or more individual(s)), each
30 minutes)
• Retraining cognition due to dementia or memory enhancement
training (i.e., CPT codes 97129; Therapeutic interventions that
focus on cognitive function (e.g., attention, memory, reasoning,
executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of
an activity (e.g., managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact;
initial 15 minutes and 97130; Therapeutic interventions that focus
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5
on cognitive function (e.g., attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning)
and compensatory strategies to manage the performance of an
activity (e.g., managing time or schedules, initiating, organizing,
and sequencing tasks), direct (one-on-one) patient contact; each
additional 15 minutes)
• Provision of support services, not requiring the skills of an individual with health psychology training.
• Provide personal, social, recreational, and general support
services.*
*While personal, social, recreational, and general support services may be valuable adjuncts to care, they are not considered psychological health behavior
interventions. Example of these services are:
•
Stress management for support staff
•
Replacement for expected nursing home staff functions
•
Recreational services, including dance, play, or art
•
Music appreciation
•
Craft skill training
•
Cooking classes
•
Individual or group social activities
•
General conversation
•
Consciousness raising
•
Vocational or religious advice
•
General educational activities
•
Visits for loneliness relief
•
Sensory stimulation
•
Games, such as bingo
•
Projects, such as shopping outings, even when used to reduce a dysphoric
state
• Teaching grooming skills
•
Grooming services
•
Monitoring activities of daily living
• Teaching the patient simple self-care
• Teaching the patient to follow simple directives
•
Wheeling the patient around the facility
•
Orienting the patient to name, date, and place
•
In-vivo exercise programs, even when designed to reduce a dysphoric state
•
Case management services including but not limited to planning activities
of daily living, arranging care or excursions, or resolving insurance problems
• All medical necessity criteria for health behavioral intervention services are not met (see medical necessity criteria in the
Section 1.E); and/or
• The family representative does not directly participate in the
plan of care; and/or
• The family representative is not present.
Health Behavior Family Intervention without the patient present
(96170/+96171) is not considered a covered service under Medicare and by some private insurers and state Medicaid programs.
Note: APA firmly believes that Health Behavior Family Intervention without the
patient present (96170/+96171) should be a reimbursable service as it benefits
the patient’s medical treatment and management; however, as coverage varies,
providers should check with their insurance carrier for verification of coverage.
Please note that this document does not provide a guarantee that
HBAI services are reimbursable under a particular plan, payer,
medical, or behavioral health benefit; therefore, it is highly recommended that providers contact each plan regarding coverage
decisions.
CODING INFORMATION
CPT Codes and Descriptors for HBAI Services
96156; Health behavior assessment or re-assessment (i.e., health-focused clinical interview, behavioral observation, clinical decision
making)
96158; Health behavior intervention, individual face-to-face; initial
30 minutes
+ 96159; Health behavior intervention, individual face-to-face; each
additional 15 minutes (List separately in addition to code for primary
service)
(Use 96159 in conjunction with 96158)
96164; Health behavior intervention, group (two or more patients),
face-to-face; initial 30 minutes
+ 96165; Health behavior intervention, group (two or more patients),
face-to-face; each additional 15 minutes (List separately in addition
to code for primary service)
• Activities principally for diversion
(Use 96165 in conjunction with 96164)
•
Planning for milieu modifications
•
Contributions to patient care plans
•
Maintenance of behavioral logs
96167; Health behavior intervention, family (with the patient present),
face-to-face; initial 30 minutes
Health Behavior Family Intervention services with the patient
present (96167/+96168) and without the patient present
(96170/+96171) will not be considered reasonable and necessary for the patient if:
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+ 96168; Health behavior intervention, family (with the patient present), face-to-face; each additional 15 minutes (List separately in
addition to code for primary service)
(Use 96168 in conjunction with 96167)
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6
96170; Health behavior intervention, family (without the patient
present), face-to-face initial 30 minutes
+ 96171; Health behavior intervention, family (without the patient
present), face-to-face; each additional 15 minutes (List separately in
addition to code for primary service)
(Use 96171 in conjunction with 96170)
• Relevant psychological and/or psychosocial history (when
appropriate)
• Sources of information (e.g., patient interview, record review,
behavioral observations)
• Services performed
+ Indicates an Add-On Code to be reported with primary service/base code
Note: APA firmly believes that Health Behavior Family Intervention without the
patient present (96170/+96171) should be a reimbursable service as it benefits
the patient’s medical treatment and management; however, as coverage varies,
providers should check with their insurance carrier for verification of coverage.
ICD-10-CM Codes that Support Medical Necessity
for HBAI Services
Due to the wide range of physical health diagnoses a patient
could have to necessitate Health Behavior Assessment and/or
Intervention services, there is not a list of “approved” codes that
support medical necessity. Instead, a list of ICD-10-CM codes
that are known not to support medical necessity when reported
as the primary diagnosis is provided in a separate addendum.
(See Addendum C for a list of non-covered primary diagnosis codes.)
• ICD-10-CM diagnosis code(s) reflecting the physical condition(s) being treated must be documented on the claim form
(Box 21 A of the CMS-1500 form) as the primary diagnosis.
• However, in the case where a patient also has a mental health
diagnosis, it should be reported as a secondary condition using
traditional mental health diagnosis codes.
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E)
ICD Incl.
A. Primary dx
B. 2* Dx
C. 3* Dx
D. 4* Dx
E.
F.
G.
H.
I.
J.
K.
L.
• ICD-10-CM codes must always be coded to the highest level
of specificity.
GENERAL INFORMATION
Documentation Requirements
The patient’s medical record should contain documentation
that supports the medical necessity for health behavior services
performed, including the following information:
• Referral question and suspected or established medical
diagnosis
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• Relevant medical history
• Clinical decision making (see description in the Section 1.B.iii)
i.
Impressions
ii. Diagnosis
iii. Treatment planning and recommendations
Documentation should be legible, signed, include the QHP’s
credentials, and maintained in the patient’s medical record.
Medical records need not be submitted with the claim; however,
all coverage criteria must be clearly documented, and the medical record, (e.g., nursing home record, doctor’s orders, progress
notes, office records, and nursing notes), must be available to
the payer upon request.
Because of the impact on the medical management of the
patient’s disease, documentation should typically show evidence
and/or attempts of communicating and coordination with the
patient’s medical provider responsible for the medical management of the physical illness that the health behavior assessment
and/or intervention was meant to address.
Documentation in the medical record must include:
• For the Assessment, evidence to support that the assessment
is reasonable and necessary (see medical necessity criteria in
the Section 1.C), and must include at a minimum the following
elements:
› Documented health-focused clinical interview,
› Diagnosis of physical illness,
› Clear rationale for why assessment or re-assessment is
required,
› Behavioral observations, including mental status and ability
to understand or respond meaningfully,
› Clinical decision-making related to the formulation of the
case conceptualization/clinical impressions, and treatment recommendations (e.g. goals and expected duration
of specific psychological intervention(s), if recommended).
• For Re-assessment, evidence to support that the re-assessment is reasonable and necessary must be documented in
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7
detailed progress notes. In addition to meeting all the criteria
for assessment (see medical necessity criteria in the Section 1.C),
these detailed progress notes must include at least one of the
following elements:
› Change in mental or medical status warranting re-evaluation;
› Specific concern from the primary medical provider or
member of medical team for why re-assessment is required;
or need for re-assessment as part of the standard of care; or
a change in providers; or at least a 6-month period of time
has elapsed since the last assessment;
› Clear indication of the precipitating event that necessitates
re-assessment; and
› Changes in goals and/or frequency and duration of services.
• For the intervention services, evidence to support that the
intervention is reasonable and necessary (see medical necessity criteria in the Section 1.E) must include, at a minimum, the
following elements:
› Evidence that the patient has the capacity to understand
and to respond meaningfully;
› Clearly defined psychological intervention provided
› Clearly stated goals of the psychological intervention
› Documentation that the psychological intervention is
expected to benefit the patient’s physical disease management and ability to comply with and/or benefit from medical interventions
› Rationale for frequency and duration of services
› The response to the intervention
As is noted in the CPT code descriptor language of the health
behavior intervention codes, these services are intended to be
reported according to the time spent providing these services.
Therefore, for all claims, start and stop times (stated in minutes)
for the health behavioral intervention encounter should be documented in the medical record, and the quantity billed should
reflect the appropriate number of base and add-on code units
required to complete the face-to-face service.
Performance of a health behavior assessment or re-assessment
includes a health-focused clinical interview, behavioral observations, and clinical decision making. Although the assessment
code is an event-based/untimed service, it is recommended that
start and stop times are documented for the face-to-face time
with the patient(s) and/or family.
Coding Guidance
If the health behavior assessment or re-assessment (CPT code
96156) is unable to be completed during a single encounter, the
date of service indicated on the claim should be the date on which
the interview was finalized.
It is typical for psychological testing and health behavior assessment and/or intervention services to be provided to the same
patient; often on the same date of service. Any psychological
testing performed in addition to the health assessment or re-assessment should be additionally reported, based on the type of
testing performed (AMA, 2004).
Health behavior assessment and intervention or two types of
health behavior intervention services can be billed on the same
date of service, but there must be clear documentation of the
provision of the two separate services and documentation of start
and stop times to distinctly delineate one service from the other.
HBAI codes should only be reported by QHP to identify assessment and treatment for psychological and/or psychosocial
factors affecting a patient’s physical health problems. The HBAI
guidelines direct that physicians, clinical nurse specialists (CNS),
or nurse practitioners (NP), performing health and behavior
assessment and/or interventions should report the appropriate
code(s) in the Evaluation and Management (E&M) or Preventive
Medicine services section of the CPT® manual. (AMA, 2014)
The HBAI CPT code family does not represent preventive medicine counseling and risk factor reduction interventions. Therefore,
they should not be reported for the purpose of prevention of a
physical illness or disability, and maintenance of health.
The family of Health Behavior services, used for patients with a
primary diagnosis that is physical in nature, have an anomalous
relationship to Psychotherapy services, used for patients with a
primary mental health diagnosis.
Biofeedback (CPT code 90901; Biofeedback training by any modality) is not covered as a health behavioral intervention.
Services to patients for evaluation and treatment of mental
illnesses should be coded using psychiatric services CPT codes
(90791-90899).
AMA CPT Health Behavior Assessment and
Intervention Guidelines
For complete coding guidance, please refer to Current Procedural Terminology (CPT®), an AMA annual publication available
at https://commerce.ama-assn.org/store/ui.
Codes in the HBAI series describe services associated with an
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acute or chronic physical illness or symptoms and are offered to
patients who may benefit from evaluations that focus on psychological and/or psychosocial factors. For patients that require
psychiatric services (90785 - 90899), adaptive behavior services
(97151-97158, 0362T, 0373T) as well as health behavior assessment and intervention, only the predominant service performed
would be reported.
Do not report HBAI codes in conjunction with psychiatric services
(90785-90899) on the same date.
Evaluation and management (E/M) service codes (including
counseling risk factor reduction and behavior change intervention [99401-99412]) should not be reported on the same day as
HBAI codes by the same provider.
HBAI can occur and be reported on the same date of service as
E/M services, as long as:
• HBAI is reported by a physician or other QHP; and
• The E/M service is reported by a different physician or other
QHP that is eligible to perform the services located in the
E/M or Preventive Medicine Services section of the 2020
CPT® Manual.
In circumstances where telehealth is available and all requirements are met for a psychologist to bill for telehealth services,
Health Behavior Assessment or Re-Assessment (96156),
Individual Intervention (96158/+96159), Group Intervention
(96164/+96165), and Family Intervention, when the patient
is present (96167/+96168), may be furnished via telehealth
to Medicare Part B beneficiaries enrolled in fee-for-service
Medicare.
UTILIZATION GUIDELINES
According to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) and Medically Unlikely Edits (MUE)
effective January 1, 2020 (CMS/NCCI, 2019):
• The initial assessment (CPT code 96156) is limited to once (1
unit) per episode of care.
• The individual intervention is limited to a maximum of 90
minutes (1 unit of 96158 and 4 units of 96159) per day, per
patient.
• The group intervention is limited to a maximum of 120 minutes
(1 unit of 96164 and 6 units of 96165) per day, per patient.
• The family intervention (with and without patient present) is
limited to a maximum of 120 minutes (1 unit of 96167/96170
and 6 units of +96168/+96171) per day, per patient.
Cumulated time is then converted to units of CPT codes reported.
A single unit of a base code should be reported with multiple units
(as needed) of the corresponding add-on code for the individual
services performed; however, add-on codes can never be reported
as a stand-alone service. They can only be reported in conjunction
with their respective base code. (See Addendum A for clinical examples and tips for proper documentation, coding and billing.)
If a health behavior intervention service exceeds the amount of
time or number of units allowed for a single service (e.g., as stated
by the NCCI and/or in an insurer policy), documentation must
be present in the patient record to justify medical necessity for
extended time provided and/or number of units reported.
Per CPT guidelines for time-based codes, a unit of service is
attained when the mid-point is passed. For example, 30 minutes
is attained when 16 minutes have elapsed (more than midway
between zero and 30 minutes). Therefore, the following standards shall apply to time measurement when reporting Health
Behavior Intervention services:
• Do not report 30-minute Health Behavior Intervention base codes
(96158, 96164, 96167, 96170) for less than 16 minutes of service.
• Do not report 15-minute Health Behavior Intervention add-on
codes (96159, 96165, 96168, and 96171) for less than 8
minutes of service.
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