How To Use CPT Code 96161

CPT 96161 refers to the administration of a caregiver-focused health risk assessment instrument, with scoring and documentation, per standardized instrument. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT code 96161.

1. What is CPT 96161?

CPT 96161 is a medical billing code used to report the administration of a caregiver-focused health risk assessment instrument. This code is utilized when a healthcare provider administers a standardized questionnaire to a patient’s caregiver, scores the results, and documents the findings. The purpose of this assessment is to identify specific health risks for the caregiver, ultimately benefiting the patient.

2. 96161 CPT code description

The official description of CPT code 96161 is: “Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument.”

3. Procedure

1. The healthcare provider selects an appropriate standardized questionnaire for the caregiver.
2. The caregiver completes the questionnaire, providing information about their health risks.
3. The healthcare provider reviews the completed questionnaire and scores the results.
4. The provider discusses the results with the caregiver, addressing any concerns or issues identified.
5. The healthcare provider documents the findings, including the specific instrument used, the scoring results, and any related discussions with the caregiver.

4. Qualifying circumstances

Eligibility for CPT code 96161 services depends on the following factors:

• The assessment is focused on the caregiver, not the patient.
• The healthcare provider administers a standardized questionnaire, which has been established and agreed upon by a group of experts.
• The purpose of the assessment is to identify specific health risks for the caregiver, ultimately benefiting the patient.
• The healthcare provider scores the results and documents the findings, including the specific instrument used, the scoring results, and any related discussions with the caregiver.

5. When to use CPT code 96161

It is appropriate to bill CPT code 96161 when a healthcare provider administers a caregiver-focused health risk assessment instrument, scores the results, and documents the findings. This code should be used for each standardized questionnaire administered, and it is essential to ensure that the assessment is focused on the caregiver, not the patient.

6. Documentation requirements

To support a claim for CPT 96161, the following information must be documented:

• The specific standardized questionnaire administered to the caregiver.
• The scoring results of the completed questionnaire.
• A summary of the discussion between the healthcare provider and the caregiver regarding the results and any identified concerns or issues.
• Confirmation that the assessment was focused on the caregiver, not the patient.

7. Billing guidelines

When billing for CPT code 96161, keep in mind the following guidelines and rules:

• Report CPT code 96161 for each standardized questionnaire administered.
• Do not report the scoring and preparation of the report separately, as they are included in the code.
• Ensure that the assessment is focused on the caregiver, not the patient.

8. Historical information

CPT 96161 was added to the Current Procedural Terminology system on January 1, 2017. There have been no updates since its addition.

9. Similar codes to CPT 96161

Five similar codes to CPT 96161 and how they differ are:

• CPT 96160: This code is used for the administration of a patient-focused health risk assessment instrument, rather than a caregiver-focused assessment.
• CPT 96127: This code is used for the administration of a brief emotional/behavioral assessment, which is different from a health risk assessment.
• CPT 96138: This code is used for the administration and scoring of psychological testing by a technician, not a healthcare provider.
• CPT 96146: This code is used for the administration of a computerized adaptive psychological test, which is different from a standardized questionnaire.
• CPT 96150: This code is used for an initial health and behavior assessment, which is a broader assessment than a caregiver-focused health risk assessment.

10. Examples

Here are 10 detailed examples of CPT code 96161 procedures:

1. A primary care physician administers a depression inventory to a caregiver of a patient with Alzheimer’s disease, scores the results, and documents the findings.
2. A pediatrician administers a stress assessment questionnaire to the caregiver of a child with autism, scores the results, and documents the findings.
3. An oncologist administers a caregiver burden assessment to the spouse of a cancer patient, scores the results, and documents the findings.
4. A geriatrician administers a caregiver strain assessment to the adult child of an elderly patient with multiple chronic conditions, scores the results, and documents the findings.
5. A psychiatrist administers a mental health risk assessment to the caregiver of a patient with bipolar disorder, scores the results, and documents the findings.
6. A neurologist administers a caregiver stress assessment to the parent of a child with epilepsy, scores the results, and documents the findings.
7. A cardiologist administers a caregiver burden assessment to the spouse of a patient with congestive heart failure, scores the results, and documents the findings.
8. An endocrinologist administers a caregiver stress assessment to the parent of a child with type 1 diabetes, scores the results, and documents the findings.
9. A rheumatologist administers a caregiver burden assessment to the adult child of a patient with rheumatoid arthritis, scores the results, and documents the findings.
10. A pulmonologist administers a caregiver strain assessment to the spouse of a patient with chronic obstructive pulmonary disease, scores the results, and documents the findings.