SUPERCEDED LCD: Centers for Medicare & Medicaid Services

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Contractor Information

Contractor Name ^{back to top}

NHIC, Corp.
Contractor Number ^{back to top}
31142
Contractor Type ^{back to top}
Carrier

LCD Information

LCD ID Number ^{back to top}

L13492

LCD Title ^{back to top}
HEALTH AND BEHAVIOR ASSESSMENT/INTERVENTION

Contractor's Determination Number ^{back to top}


AMA CPT / ADA CDT Copyright Statement ^{back to top}
CPT codes, descriptions and other data only are copyright 2009 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy ^{back to top}
Title XVIII of the Social Security Act, Section 1862(a)(7) excludes routine physical examination and screening tests performed in the absence of signs or symptoms from coverage. Title XVIII of the Social Security Act, Section 1862(a)(1)(A) allows coverage and payment for services considered medically reasonable and necessary. Title XVIII of the Social Security Act, Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. CMS Manual System, Pub 100-3, Medicare National Coverage Determinations Manual, Section 40.1 CMS Manual System, Pub 100-3, Medicare National Coverage Determinations Manual, Section 180.1 Code of Federal Regulation, Part 410.73(b)(1), "The Services of a clinical social worker are limited to the diagnosis and treatment of mental illness."

Primary Geographic Jurisdiction ^{back to top}
Massachusetts Maine New Hampshire Vermont

Oversight Region ^{back to top}
Region I

Original Determination Effective Date ^{back to top}
For services performed on or after 01/15/2004

Original Determination Ending Date ^{back to top}


Revision Effective Date ^{back to top}
For services performed on or after 02/01/2006

Revision Ending Date ^{back to top}


Indications and Limitations of Coverage and/or Medical Necessity ^{back to top}
Health and Behavior Assessment procedures are used to identify the psychological, behavioral, emotional, cognitive, and social factors important to the prevention, treatment, or management of physical health problems. The focus is not on mental health, but on the biopsychosocial factors important to physical health problems and treatments. [Current Procedural Terminology, CPT 2002, American Medical Association, St Anthony's Publishing, Professional Edition, p.368.] Health and Behavior Intervention procedures are used to modify the psychological, behavioral, emotional, cognitive and social factors identified as important to or directly affecting the patient’s physiological functioning, disease status, health, and well-being. The focus of the intervention is to improve the patient's health and well-being utilizing cognitive, behavioral, social, and/or psychophysiological procedures designed to ameliorate specific disease-related problems. [Current Procedural Terminology, CPT 2002, American Medical Association, St Anthony's Publishing, Professional Edition, p.368.] INDICATIONS OF COVERAGE: The Initial Health and Behavior Assessment (CPT Code 96150) is considered reasonable and necessary for the patient: Who has an underlying physical illness or injury, and For whom the purpose of the assessment is not for the diagnosis or treatment of mental illness, and For whom there is reason to believe that a biopsychosocial factor may be significantly affecting the treatment, or medical management of an illness or an injury, and Who is expected to have the capacity to understand or respond meaningfully to the psychological intervention, and For whom there is documented need from the patient’s attending physician that he or she needs psychological assessment to successfully manage his/her physical illness to resolve the psychological barriers to the management of his/her physical disease and activities of daily living, and For whom the assessment is not duplicative of other provider assessments The Health and Behavior Reassessment (CPT Code 96151) is considered reasonable and necessary for the patient: Who has an underlying physical illness or injury, and For whom the purpose of the reassessment is not for the diagnosis or treatment of mental illness, and For whom there is a question of a sufficient change in psychological or medical status warranting re-evaluation of his or her capacity to understand or to respond meaningfully to the psychological intervention, and For whom the need for reassessment has been documented by the patient’s attending physician, and For whom the reassessment is not duplicative of other provider assessments The Health and Behavior Intervention (CPT Codes 96152-96153) is considered reasonable and necessary for the patient(s): Who have an underlying physical illness or injury, and For whom the purpose of the intervention is not the treatment of mental illness, and Who are expected to have the capacity to understand or respond meaningfully to the psychological intervention, and Who require psychological intervention to address: Non-compliance with the medical treatment plan, or The biopsychosocial 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, behaviors which place the patient or others at risk for safety, health-related risk-taking behaviors, and overall adjustment to medical illness, and For whom the specific psychological intervention(s) and patient outcome goal(s) have been clearly identified The Health and Behavior Intervention (with the family and patient present)(CPT Code 96154) is considered reasonable and necessary for patient and family representative: The family representative directly participates in the care of the patient, and The psychological intervention with the patient and family is necessary to address biopsychosocial factors that affect compliance with the plan of care, symptom management, health- promoting behaviors, behaviors which place the patient or others at risk for safety, health-related risk-taking behaviors, and overall adjustment to medical illness. Definitions: Family representative is defined as one of the following: Immediate family members (husband, wife, domestic partner, siblings, children, grandchildren, grandparents, mother, father) Primary caregiver who provides care on a voluntary, uncompensated, regular, sustained basis Guardian, or health care proxy LIMITATIONS OF COVERAGE:* When the indications of coverage have not been met. Health and behavioral intervention services are not considered reasonable and necessary to: Update or educate the family about the patient's condition Educate non-immediate family members, non-primary care-givers, non-guardians, the non-health care proxy, 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 Mediate between family members or provide family psychotherapy Educate diabetic patients and diabetic patients' family members² Deliver Medical Nutrition Therapy³ Maintain the patient's or family's existing health and overall well-being Provide personal, social, recreational, and general support services. These services may be valuable adjuncts to care; however, they are not psychological interventions. Examples 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 and relaxation Craft skill training Cooking classes Comfort care services Individual social activities Teaching social interaction skills Socialization in a group setting Retraining cognition due to dementia General conversation Services directed toward making a more dynamic personality Consciousness raising Vocational or religious advice General educational activities Tobacco withdrawal support Caffeine withdrawal support Visits for loneliness relief Sensory stimulation Games, including bingo games Projects, including letter writing Entertainment Excursions, including 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 Exercise programs, even when designed to reduce a dysphoric state Memory enhancement training Weight loss management Case management services including but not limited to planning activities of daily living, arranging care or excursions, or resolving insurance problems Activities principally for diversion Planning for milieu modifications Contributions to patient care plans Maintenance of behavioral logs Provision of support services, not requiring the skills of a Clinical Psychologist (CP) (Specialty Code 68). When a health and behavior assessment/intervention service is not rendered, e.g.: Reviewing activity therapy reports Supervising nursing and ancillary personnel Leading or directing treatment teams Only monitoring the behavioral effects of medications Only providing medication recommendation

Coding Information

Bill Type Codes: ^{back to top}

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes: ^{back to top}

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes ^{back to top}

96150	HEALTH AND BEHAVIOR ASSESSMENT (EG, HEALTH-FOCUSED CLINICAL INTERVIEW, BEHAVIORAL OBSERVATIONS, PSYCHOPHYSIOLOGICAL MONITORING, HEALTH-ORIENTED QUESTIONNAIRES), EACH 15 MINUTES FACE-TO-FACE WITH THE PATIENT; INITIAL ASSESSMENT
96151	HEALTH AND BEHAVIOR ASSESSMENT (EG, HEALTH-FOCUSED CLINICAL INTERVIEW, BEHAVIORAL OBSERVATIONS, PSYCHOPHYSIOLOGICAL MONITORING, HEALTH-ORIENTED QUESTIONNAIRES), EACH 15 MINUTES FACE-TO-FACE WITH THE PATIENT; RE-ASSESSMENT
96152	HEALTH AND BEHAVIOR INTERVENTION, EACH 15 MINUTES, FACE-TO-FACE; INDIVIDUAL
96153	HEALTH AND BEHAVIOR INTERVENTION, EACH 15 MINUTES, FACE-TO-FACE; GROUP (2 OR MORE PATIENTS)
96154	HEALTH AND BEHAVIOR INTERVENTION, EACH 15 MINUTES, FACE-TO-FACE; FAMILY (WITH THE PATIENT PRESENT)

ICD-9 Codes that Support Medical Necessity ^{back to top}

Any ICD-9-CM Medical diagnosis only

XX000 Not Applicable

Diagnoses that Support Medical Necessity ^{back to top}

Medical diagnoses only

ICD-9 Codes that DO NOT Support Medical Necessity ^{back to top}

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation ^{back to top}

Diagnoses that DO NOT Support Medical Necessity ^{back to top}

General Information

Documentation Requirements ^{back to top}

Note: Because of the impact on the medical management of the patient's disease, documentation must show evidence of coordination of care with the patient's primary medical care providers or medical provider responsible for the medical management of the physical illness that the psychological assessment/intervention was meant to address.

Evidence of a referral to the Clinical Psychologist by the medical provider responsible for the medical management of the patient’s physical illness must be documented in the medical record for the initial assessment and for reassessment.

Documentation in the medical record by the Clinical Psychologist (CP) Specialty Code 68), must include:
- For the initial assessment, evidence to support that the assessment is reasonable and necessary, and 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
  - Goals and expected duration of specific psychological intervention(s), if recommended.
- For reassessment, evidence to support that the reassessment is reasonable and necessary must be documented in detailed progress notes.
  These detailed progress notes must include the following elements:
  - Date of change in psychological or medical status requiring reassessment, and
  - Clear rationale for why reassessment is required, and
  - Clear indication of the precipitating event that necessitates reassessment
- For the intervention service, evidence to support that the intervention is reasonable and necessary must include, at a minimum, the following elements:
  - Evidence that the patient has the capacity to understand or to respond meaningfully, and
  - Clearly defined psychological intervention planned, and
  - The goals of the psychological intervention should be stated clearly
  - There should be documentation that the psychological intervention is expected to improve compliance with the medical treatment plan, and
  - The response to the intervention must be indicated, and
  - Rationale for frequency and duration of services

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, and the quantity billed should reflect 1 unit for each 15 minutes, e.g., one hour equals 4 units of service.

ICD-9-CM diagnosis code(s) reflecting the physical condition(s) being treated must be present on the claim as the primary diagnosis.

Documentation to support that the indications of coverage have been met

Medical records need not be submitted with the claim; however, the medical record, e.g., complete nursing home record, doctor's orders, progress notes, office records, and nursing notes, must be available to the Carrier upon request.

Appendices ^{back to top}

Utilization Guidelines ^{back to top}

The initial assessment is limited to a maximum of one hour (4 units) regardless of the number of sessions.
A reassessment is limited to a maximum of one hour (4 units) regardless of the number of sessions.
The intervention is limited to a maximum of twelve hours (48 units) regardless of the number of sessions.

Sources of Information and Basis for Decision ^{back to top}

1. Current Procedural Terminology, CPT 2003, American Medical Association, Professional Edition, p.386.

2. CMS Manual System, Pub 100-3, Medicare National Coverage Determinations Manual, Section 40.1

3. CMS Manual System, Pub 100-3, Medicare National Coverage Determinations Manual, Section 180.1

4. ICD-9-Expert, 2002, sixth edition, St. Anthony Publishing/Medicode.

5. CPT Changes, An Insider's View, 2002, American Medical Association, pages 218-220.

6. Carrier Advisory Committee Psychiatry Working Group.

Advisory Committee Meeting Notes ^{back to top}

Psychiatry, Psychology, Clinical Social Work, Clinical Nurse Specialist.

Start Date of Comment Period ^{back to top}

08/11/2003

End Date of Comment Period ^{back to top}

09/25/2003

Start Date of Notice Period ^{back to top}

12/01/2003

Revision History Number ^{back to top}

Revision History Explanation ^{back to top}

R4
02/01/2006
Deleted from Limitations of Coverage section: "A claim for Health and Behavior Assessment or Intervention services is submitted without the name and UPIN number of the referring physician or qualified non-physician practitioner will be returned as an incomplete claim under 1833(e)"

Revised the maximum number of hours for intervention from 2 hours (8 units)to twelve hours (48 units)in the Utilization Guidelines section.

R3
11/08/2004
Technical Correction: Code of Federal Regulation, Part 410.73(b)(1), "The Services of a clinical social worker are limited to the diagnosis and treatment of mental illness", added to the CMS National Coverage Policy Section.

02/02/2004
National Coverage Policy crosswalked to CMS Manual System (Internet Only Manual).

R1
01/23/2004
This LCD was converted from an LMRP on 01/23/2004.
The LMRP description was added to the Indications and Limitations Section of the LCD.

Reason for Change ^{back to top}

Last Reviewed On Date ^{back to top}

04/03/2007

Medicare Coverage Database

LCD for HEALTH AND BEHAVIOR ASSESSMENT/INTERVENTION (L13492)