- Can the new health and behavior CPT codes be billed immediately?
- Is Medicare now reimbursing the new codes?
- Where are the descriptions of the new code numbers?
- What types of services will the new codes be used to describe?
- Do the new codes capture a preventive medicine service?
- Who is eligible to use these codes?
- Can psychologists bill Evaluation and Management Codes to report these services to Medicare and private insurance plans?
- Can a DSM-IV diagnosis code used in conjunction with these services?
- Will psychologists be expected to establish a physical diagnosis under the ICD-9 CM when reporting the new codes?
- Where will the funding for services covered by the new codes come from?
- Does the Medicare “Outpatient Mental Health Treatment Limitation” apply to services provided under the new codes?
- What are the Medicare reimbursement rates for the new codes?
- Will private insurers pay the same reimbursement rates as Medicare?
- How are these codes reported to Medicare and private insurers?
- Are there any Medicare coding standards that psychologists should be aware of aware of when using these codes?
- Are there any compliance issues under the NCCI to be aware of when using these codes?
- Where can I find information about facility billing of services captured under the new codes?
- Whom should I contact about carrier denials for these services?
- Should I contact APA if I have problems billing these codes?
- Are there any additional resources for information about the new codes?
As of January 1, 2002, health and behavior assessment and intervention CPT codes can be reported to Medicare and private-third party payers for psychological services that treat behavioral, social, and psychophysiological conditions for the treatment or management of physical health problems. With the introduction of the new codes, the Practice Directorate continues to receive many questions from psychologists asking how to integrate the new CPT codes into their practice. This material was prepared in an effort to address the most frequently asked questions.
1. Can the new health and behavior CPT codes be billed immediately?
Yes, services rendered under the new codes can be billed to Medicare and private insurers as of January 1, 2002.
However, private third-party insurance plans may have developed payment policies that are more or less restrictive than under Medicare, which could affect reimbursement for these codes. Psychologists should check with private insurers about exclusive payment policies.
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2. Is Medicare now reimbursing the new codes?
Yes. Medicare recognized the codes as eligible for reimbursement effective January 1, 2002. Some reimbursement problems were initially apparent when a carrier considered the services to be preventive in nature. Following intervention by the APA Practice Directorate, the Centers for Medicare and Medicaid Services (CMS) instructed the carrier to issue a corrected notice stating that services under the codes were not preventive and therefore would be paid by Medicare.
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3. Where are the descriptions of the new code numbers?
The health and behavior assessment and intervention codes can be found in a new section of the 2002 CPT manual entitled "Health and Behavior Assessment and Intervention".
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4. What types of services will the new codes be used to describe?
Typically, health and behavior assessment and intervention services address an assortment of physical health issues, including patient adherence to medical treatment, symptom management, health-promoting behaviors, health-related risk-taking behaviors, and overall adjustment to physical illness.
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5. Do the new codes capture a preventive medicine service?
No, health and behavior assessment and intervention services are delivered to patients with an established physical health problem, which has been diagnosed by a physician.
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6. Who is eligible to use these codes?
Psychologists, nurses, licensed clinical social workers, and other healthcare clinicians whose scope of practice permits, can bill the new codes. However, physicians must report services captured by these codes under Evaluation and Management service codes.
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7. Can psychologists bill Evaluation and Management Codes to report these services to Medicare and private insurance plans?
Psychologists cannot bill Evaluation and Management (E&M) codes when treating Medicare beneficiaries because the Center for Medicare and Medicaid Services (CMS) currently restricts the use of these codes. CMS restricts the use of E&M codes to physicians because it is the agency's position that these codes involve services unique to medical management such as medical diagnostic evaluation, drug management, and interpreting laboratory or other medical diagnostic studies.
Although there are some similarities among the services, the health and behavior codes should not be viewed as a substitute for E&M. APA is continuing its advocacy with CMS to permit psychologists to be reimbursed for providing E&M services to Medicare beneficiaries.
Psychologists treating patients with private insurance may be able to bill for E&M services because not all insurers impose the same restriction as Medicare. Psychologists should check with the private carrier to determine its policy on E&M.
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8. Can a DSM-IV diagnosis code used in conjunction with these services?
No, an ICD-9 CM physical diagnosis code would be linked to these services since health and behavior assessment and intervention services focus on patients whose primary diagnosis is a physical health problem.
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9. Will psychologists be expected to establish a physical diagnosis under the ICD-9 CM when reporting the new codes?
No, the psychologist’s scope of practice prohibits the clinician from making a diagnosis of a physical health problem and therefore, the existing medical diagnosis made by a physician will be used when reporting services captured under the new codes.
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10. Where will the funding for services covered by the new codes come from?
Federal reimbursement for health and behavior assessment and intervention services delivered under Medicare will be drawn from monies for medical instead of psychiatric services and so, will not deplete limited mental health funds.
For private third party insurance plans, we expect these services to be treated under the physical illness benefits and thus, not be relegated to behavioral health “carve out” provisions.
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11. Does the Medicare “Outpatient Mental Health Treatment Limitation” apply to services provided under the new codes?
No, under current Federal regulations, the Medicare outpatient mental health treatment limitation 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. Health and behavior assessment and intervention services rendered in the outpatient environment will be reimbursed at 80% (instead of the 50% that Medicare pays for mental health services) so long as the patients have a medical, and not a psychiatric diagnosis that falls within the regulation.
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12. What are the Medicare reimbursement rates for the new codes?
Estimated Medicare reimbursement rates for 2002 are listed below. To find out
exact payments for health and behavior assessment and intervention services, psychologists should check with their local Medicare carriers in their geographic area.
| CPT Code |
Service |
Approximate Medicare Payment |
| |
|
(15 min – 1 unit) |
(1 hr – 4 units) |
| 96150 |
Assessment – initial |
$26 * |
$106 * |
| 96151 |
Re-assessment |
$26 |
$103 |
| 96152 |
Intervention – individual |
$25 |
$98 |
| 96153 |
Intervention – group (per person) |
$5 ** |
$22 ** |
| 96154 |
Intervention – family w/ patient |
$24 |
$96 |
| 96155 |
Intervention – family w/o patient |
$23 |
$93 |
| |
| * Multiple-unit differences are due to rounding |
| ** Total group fee equals amount times number of persons in group |
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13. Will private insurers pay the same reimbursement rates as Medicare?
Because private third-party insurance plans may have payment policies that differ from Medicare, psychologists should check with the insurer to find out about the reimbursement rates for the new codes.
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14. How are these codes reported to Medicare and private insurers?
Each code is based on 15 minutes of service, face-to-face contact with the patient. Consequently, psychologists would report 1 unit per 15 minutes of the service. For example, a psychologist would bill 2 units for a 30-minute service and 3 units for a 45-minute service. When the service falls between units, the healthcare provider must round up or down to the nearest increment. To illustrate, a psychologist would bill 3 units for a 50-minute service but would bill 4 units for a 55-minute service.
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15. Are there any Medicare coding standards that psychologists should be aware of aware of when using these codes?
Yes, the new codes are subject to the National Correct Coding Initiative (NCCI).
The NCCI is a series of correct coding methodologies that are based in part, on the coding standards defined in the American Medical Association’s CPT manual, coding guidelines of numerous national specialty societies, principles of customary medical practice, and a continuous assessment of current coding practice. Because CMS believes that accurate coding and billing of healthcare services to Medicare is crucial, it developed the NCCI to aid healthcare providers to properly code their services for reimbursement.
A number of private third-party payers have adopted the NCCI but some insurers have developed coding guidelines of their own. Again, psychologists should check with private insurance plans about guidelines that are different from coding conventions under Medicare.
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16. Are there any compliance issues under the NCCI to be aware of when using these codes?
Yes, under the NCCI:
- Health and behavior assessment and intervention codes cannot be used for treating patients with a psychiatric diagnosis.
- The clinician cannot bill psychiatric codes (CPT codes 90801- 90899) and health and behavior assessment and intervention codes (CPT codes 96150 - 96155) on the same day. For services rendered to patients that require both psychiatric and health and behavior assessment and intervention services, the clinician must report the principal service being provided.
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17. Where can I find information about facility billing of services captured under the new codes?
Psychologists can get information from their local fiscal intermediary or CMS regional office about billing Medicare for these codes in a facility setting. When dealing with private third-party payers, psychologists should contact the individual insurer about their procedures for facility billing.
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18. Whom should I contact about carrier denials for these services?
If psychologists receive denials from Medicare after reporting services associated with the new codes, they should contact their local Medicare carrier or the CMS regional office in their area to find out what the problem is. In the case of an outright denial of a claim, Medicare offers an appeals process to providers at the local level. A majority of local Medicare carriers have web sites where information on appeals can be found.
Psychologists reporting services to private insurance plans should check with the carrier about appeal opportunities available to them.
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19. Should I contact APA if I have problems billing these codes?
Yes. APA wants to know about any difficulties psychologists experience in billing these codes with either Medicare or private insurers. Psychologists should contact the Practice Directorate’s Government Relations Office at (202) 336-5889.
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20. Are there any additional resources for information about the new codes?
Yes, Psychologists can visit the Practice Directorate website at under http://www.apa.org/practice/cpt_2002.html. Psychologists can also contact either their local Medicare carrier or the office of the Center for Medicare and Medicaid Services in their region. Information about the new CPT codes can also be located in the 2002 CPT manual under "Health and Behavior Assessment and Intervention".
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