How To Use CPT Code 96156

CPT 96156 is a code used for health behavior assessment or re-assessment, focusing on factors affecting a patient’s physical health. This article will cover the description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 96156.

1. What is CPT 96156?

CPT 96156 is a code used to report health behavior assessment or re-assessment services provided by healthcare professionals. The focus of this assessment is on psychological, behavioral, emotional, cognitive, and social factors that affect a patient’s physical health, rather than assessing a specific mental health disorder. This code can be used for both initial and repeat health behavior assessments.

2. 96156 CPT code description

The official description of CPT code 96156 is: “Health behavior assessment, or re-assessment (i.e., health-focused clinical interview, behavioral observations, clinical decision making)”.

3. Procedure

  1. The provider assesses the patient’s psychological factors affecting their current state of health by asking questions about their health and how their illness affects their activities.
  2. Behavioral observations are made in response to questions or situations, and the patient’s physical and emotional responses to various situations are noted.
  3. Standardized health-related surveys may be administered to gather additional information.
  4. The provider reviews the patient’s medical, family, and social history, current complaints, and the nature, severity, and duration of symptoms.
  5. The patient’s response to their diagnosis, illness, or injury is evaluated, along with their perception of the prognosis for the disease, coping strategies, and adherence to medical treatment.
  6. Observations are made on the patient’s facial expressions, posture, and gestures, as well as their communication of emotional concerns and how they relate to the provider and others present during the interview.
  7. The provider identifies psychophysiological, behavioral, and social factors that interfere with treatment and management of the patient’s physical health problems and develops a plan for intervention to enable the patient to overcome those barriers to self-management of their chronic disease.

4. Qualifying circumstances

Patients who may be eligible to receive CPT code 96156 services include those experiencing difficulties in managing their physical health due to psychological, behavioral, emotional, cognitive, or social factors. Examples of such patients may include those who are combative due to painful medical treatments or those in constant pain. The focus of the assessment should be on factors affecting the patient’s physical health, not on mental health issues.

5. When to use CPT code 96156

It is appropriate to bill the 96156 CPT code for an initial or repeat health behavior assessment when the provider is assessing factors affecting a patient’s physical health, rather than a specific mental health disorder. This code can be used regardless of the amount of time spent with the patient. However, be prepared to document changes in diagnoses and/or symptoms to justify more than one repeat health behavior assessment, as some payers may limit the number of times a repeat assessment can be performed.

6. Documentation requirements

To support a claim for CPT 96156, the following information should be documented:

  • A detailed description of the health behavior assessment or re-assessment, including the clinical interview, behavioral observations, and clinical decision making.
  • Identification of the psychophysiological, behavioral, and social factors that interfere with the patient’s treatment and management of their physical health problems.
  • A plan for intervention to help the patient overcome barriers to self-management of their chronic disease.
  • Documentation of the patient’s medical, family, and social history, current complaints, and the nature, severity, and duration of symptoms.
  • Evidence of the patient’s response to their diagnosis, illness, or injury, their perception of the prognosis for the disease, coping strategies, and adherence to medical treatment.

7. Billing guidelines

When billing for CPT code 96156, it is important to follow the guidelines and rules set by the Centers for Medicare & Medicaid Services (CMS) and other payers. In addition to reporting CPT 96156, you must also report a diagnosis (ICD-10-CM) code and an Evaluation and Management (E/M) or preventive medicine service code. Documentation must support the specific established underlying diagnosis. Do not report CPT 96156 in conjunction with mental illness diagnosis codes or psychotherapy services codes.

8. Historical information

CPT 96156 was added to the Current Procedural Terminology system on January 1, 2020. There have been no updates to the code since its addition.

9. Similar codes to CPT 96156

Five similar codes to CPT 96156 and how they differentiate from CPT 96156 are:

  1. CPT 96158: This code is used for individual health behavior intervention, initial 30 minutes, and focuses on intervention rather than assessment.
  2. CPT 96164: This code is used for group health behavior intervention, initial 30 minutes, and is intended for group settings rather than individual assessments.
  3. CPT 96167: This code is used for family health behavior intervention, initial 30 minutes, and is intended for family settings rather than individual assessments.
  4. CPT 96170: This code is used for health behavior intervention, each additional 15 minutes, and is an add-on code for extended intervention time.
  5. CPT 96171: This code is used for family health behavior intervention, each additional 15 minutes, and is an add-on code for extended intervention time in family settings.

10. Examples

Here are 10 detailed examples of CPT code 96156 procedures:

  1. A patient with diabetes struggling to adhere to their medication regimen and dietary recommendations due to stress and anxiety.
  2. A patient with chronic pain who is experiencing difficulty coping with their condition and maintaining daily activities.
  3. A patient with hypertension who is having trouble managing their stress levels, leading to poor blood pressure control.
  4. A patient with cancer who is struggling with emotional distress and needs support in managing their treatment and side effects.
  5. A patient with asthma who is experiencing anxiety related to their condition, leading to poor adherence to their inhaler regimen.
  6. A patient with heart disease who is having difficulty adjusting to lifestyle changes, such as diet and exercise, due to depression.
  7. A patient with obesity who is struggling with emotional eating and needs support in developing healthier coping strategies.
  8. A patient with chronic obstructive pulmonary disease (COPD) who is experiencing difficulty managing their symptoms due to anxiety and depression.
  9. A patient with irritable bowel syndrome (IBS) who is struggling with stress management, leading to exacerbation of their symptoms.
  10. A patient with fibromyalgia who is experiencing difficulty coping with their chronic pain and needs support in managing their condition and daily activities.

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