Health and Behavior Assessment/Intervention (L30514)
Contractor Information
|
Contractor Name Wisconsin Physicians Service Insurance Corporation |
Contractor Number 00951, 00952, 00953, 00954, 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402 |
Contractor Type Carrier - FI - MAC |
LCD Information
Document Information
L30514 LCD Title Health and Behavior Assessment/Intervention Contractor's Determination Number PSYCH-015 AMA CPT/ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2010 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. |
Primary Geographic Jurisdiction
Oversight Region Original Determination Effective Date For services performed on or after 03/18/2010 Original Determination Ending Date Revision Effective Date For services performed on or after 02/21/2011 Revision Ending Date |
CMS National Coverage Policy
Title XVIII of the Social Security Act section 1862 (a)(1)(A)..
Title XVIII of the Social Security Act section 1862 (a)(7).
Title XVIII of the Social Security Act section §1833 (c) and §1833 (e).
CFR Title 42, Part 410.73(b)(1)[CITE: 42CFR410.73] (CMS) of the Act and in §2470ff
Title XVIII of the Social Security Act section 1862 (a)(7).
Title XVIII of the Social Security Act section §1833 (c) and §1833 (e).
CFR Title 42, Part 410.73(b)(1)[CITE: 42CFR410.73] (CMS) of the Act and in §2470ff
Indications and Limitations of Coverage and/or Medical Necessity
Health and Behavior Assessment procedures identify the psychological, behavioral, emotional, cognitive, and social factors important to the prevention, treatment or management of physical health problems. The focus of the assessment is not on mental health but on the biopsychosocial factors important to physical health problems and treatments.
Health and Behavior Intervention procedures modify the psychological, behavioral, emotional, cognitive, and social factors identified as important to or directly affecting the beneficiary's physiological functioning, health and well being, or specific disease-related problems.
CPT codes 96150-96154 are reported to describe services, performed to address difficulties associated with an acute or chronic illness, prevention of a physical illness or disability and maintain health, that do not meet criteria for a psychiatric diagnosis.
1. The Health and Behavioral Assessment, initial (CPT code 96150) and Reassessment (CPT code 96151), and Intervention services (CPT codes 96152-96153) may be considered reasonable and necessary for the beneficiary who meets all of the following criteria:
a. The beneficiary has an underlying physical illness or injury, and
b. The purpose of the assessment is not for the diagnosis or treatment of mental illness, and
c. 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
d. The beneficiary is alert, oriented and has the capacity to understand and to respond meaningfully during the face-to-face encounter, and
e. The beneficiary has a documented need for psychological support in order to successfully manage his/her physical illness, and activities of daily living, and
f. The assessment is not duplicative of other provider assessments
2. Health and Behavioral Re-assessment (CPT code 96151) will be considered reasonable and necessary, if documentation indicates that there has been a sufficient change in mental or medical status warranting re-evaluation of the beneficiary's capacity to understand and to respond meaningfully to the psychological intervention.
3. Health and Behavioral Intervention, individual or group (two or more beneficiaries) (CPT codes 96152-96153) require that:
a. Specific psychological intervention(s) and beneficiary outcome goal(s) have been clearly identified, and
b. Psychological intervention is necessary to address:
- Non-compliance with the medical treatment plan, or
- The biopsychosocial factors associated with a new 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, and overall adjustment to medical illness, and
c. The specific psychological interventions(s) and beneficiary outcome goals have been clearly identified.
4. Health and Behavioral Intervention (with the family and beneficiary present) (CPT code 96154) is considered reasonable and necessary for the beneficiary who meets all of the following criteria:
a. The family representative directly participates in the overall care of the beneficiary, and
b. The psychological intervention with the beneficiary and family is necessary to address biopsychosocial factors that affect compliance with the plan of care, symptom management, health-promoting behaviors, health-related risk-taking behaviors, and overall adjustment to medical illness.
For the purpose of this policy, 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
1. Health and Behavioral Assessment/Intervention is not considered reasonable and necessary for beneficiaries who:
a. Do not have an underlying physical illness or injury, or
b. Have been diagnosed with mental illness, or
c. Who have no documented indication that a biopsychosocial factor may be significantly affecting the treatment, or medical management of an illness or injury, or
d. Do not have the capacity to understand and to respond meaningfully during the face-to-face encounter, because of:
- Dementia that has produced a severe enough cognitive defect for the psychological intervention to be ineffective.
- Delirium
- Severe and profound mental retardation
- Persistent vegetative state or no discernible consciousness,
- Impaired mental status, e.g.
- disorientation to person, time, place, purpose, or
- inability to recall current season, location of own room, names and faces, or
- inability to recall that he or she is in a nursing home or skilled nursing facility
2. Health and Behavioral Assessment/Intervention is not considered reasonable and necessary for beneficiaries who do not require psychological support to successfully manage his/her physical illness through identification of the barriers to the management of physical disease and activities of daily living.
3. Health and Behavioral Assessment/Intervention is not considered reasonable and necessary for beneficiaries who do not have the conditions noted under the indications portion of this section.
4. Health and Behavioral Intervention with the family and beneficiary present is not considered reasonable and necessary for the beneficiary if:
a. It is not necessary to ensure beneficiary compliance with the medical treatment plan, or
b. The family representative does not directly participate in the plan of care, or
c. The family representative is not present.
d. There is no face-to-face encounter with the beneficiary.
5. Health and Behavioral Intervention services are not considered reasonable and necessary to:
a. Update or educate the family about the beneficiary's condition
b. Educate non-immediate family members, non-primary caregivers, 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 beneficiary's care plan.
c. Treatment-planning with staff
d. Mediate between family members or provide family psychotherapy
e. Educate diabetic beneficiaries and diabetic beneficiaries family members
f. Deliver Medical Nutrition Therapy
g. Maintain the beneficiary's or family's existing health and overall well-being
h. Provide personal, social, recreational, and general support services may be valuable adjuncts to care; however, they are not psychological interventions.
6. Health and Behavioral Assessment/Intervention (CPT codes 96150-96154) may only be performed by a Clinical Psychologist (CP Specialty Code 68).
7. Health and Behavioral Assessment/Intervention (CPT codes 96150-96154) may not be billed by physicians or non-physician practitioners (example: medical doctor, nurse practitioner, physician assistant, clinical nurse practitioner) or clinical social worker services.
8. Biofeedback as a behavioral modification technique will be limited to those indications recognized under the national coverage determination (30.1, publication 100-3,
http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx(external link)
Examples of services that are not considered part of Health and Behavioral Intervention services are:
Stress management for support staff
Replacement for expected nursing home staff functions
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 or caffeine withdrawal support
Visits for loneliness relief
Sensory stimulation
Games, including bingo games
Project, including letter writing
Entertainment
Excursions, including shopping outing, even when used to reduce a dysphoric state
Teaching grooming skills
Grooming services
Monitoring activities of daily living
Teaching the beneficiary simple self-care
Teaching the beneficiary to follow simple directives
Wheeling the beneficiary around the facility
Orienting the beneficiary 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 beneficiary care plans
Maintenance of behavioral logs
Health and Behavior Intervention procedures modify the psychological, behavioral, emotional, cognitive, and social factors identified as important to or directly affecting the beneficiary's physiological functioning, health and well being, or specific disease-related problems.
CPT codes 96150-96154 are reported to describe services, performed to address difficulties associated with an acute or chronic illness, prevention of a physical illness or disability and maintain health, that do not meet criteria for a psychiatric diagnosis.
1. The Health and Behavioral Assessment, initial (CPT code 96150) and Reassessment (CPT code 96151), and Intervention services (CPT codes 96152-96153) may be considered reasonable and necessary for the beneficiary who meets all of the following criteria:
a. The beneficiary has an underlying physical illness or injury, and
b. The purpose of the assessment is not for the diagnosis or treatment of mental illness, and
c. 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
d. The beneficiary is alert, oriented and has the capacity to understand and to respond meaningfully during the face-to-face encounter, and
e. The beneficiary has a documented need for psychological support in order to successfully manage his/her physical illness, and activities of daily living, and
f. The assessment is not duplicative of other provider assessments
2. Health and Behavioral Re-assessment (CPT code 96151) will be considered reasonable and necessary, if documentation indicates that there has been a sufficient change in mental or medical status warranting re-evaluation of the beneficiary's capacity to understand and to respond meaningfully to the psychological intervention.
3. Health and Behavioral Intervention, individual or group (two or more beneficiaries) (CPT codes 96152-96153) require that:
a. Specific psychological intervention(s) and beneficiary outcome goal(s) have been clearly identified, and
b. Psychological intervention is necessary to address:
- Non-compliance with the medical treatment plan, or
- The biopsychosocial factors associated with a new 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, and overall adjustment to medical illness, and
c. The specific psychological interventions(s) and beneficiary outcome goals have been clearly identified.
4. Health and Behavioral Intervention (with the family and beneficiary present) (CPT code 96154) is considered reasonable and necessary for the beneficiary who meets all of the following criteria:
a. The family representative directly participates in the overall care of the beneficiary, and
b. The psychological intervention with the beneficiary and family is necessary to address biopsychosocial factors that affect compliance with the plan of care, symptom management, health-promoting behaviors, health-related risk-taking behaviors, and overall adjustment to medical illness.
For the purpose of this policy, 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
1. Health and Behavioral Assessment/Intervention is not considered reasonable and necessary for beneficiaries who:
a. Do not have an underlying physical illness or injury, or
b. Have been diagnosed with mental illness, or
c. Who have no documented indication that a biopsychosocial factor may be significantly affecting the treatment, or medical management of an illness or injury, or
d. Do not have the capacity to understand and to respond meaningfully during the face-to-face encounter, because of:
- Dementia that has produced a severe enough cognitive defect for the psychological intervention to be ineffective.
- Delirium
- Severe and profound mental retardation
- Persistent vegetative state or no discernible consciousness,
- Impaired mental status, e.g.
- disorientation to person, time, place, purpose, or
- inability to recall current season, location of own room, names and faces, or
- inability to recall that he or she is in a nursing home or skilled nursing facility
2. Health and Behavioral Assessment/Intervention is not considered reasonable and necessary for beneficiaries who do not require psychological support to successfully manage his/her physical illness through identification of the barriers to the management of physical disease and activities of daily living.
3. Health and Behavioral Assessment/Intervention is not considered reasonable and necessary for beneficiaries who do not have the conditions noted under the indications portion of this section.
4. Health and Behavioral Intervention with the family and beneficiary present is not considered reasonable and necessary for the beneficiary if:
a. It is not necessary to ensure beneficiary compliance with the medical treatment plan, or
b. The family representative does not directly participate in the plan of care, or
c. The family representative is not present.
d. There is no face-to-face encounter with the beneficiary.
5. Health and Behavioral Intervention services are not considered reasonable and necessary to:
a. Update or educate the family about the beneficiary's condition
b. Educate non-immediate family members, non-primary caregivers, 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 beneficiary's care plan.
c. Treatment-planning with staff
d. Mediate between family members or provide family psychotherapy
e. Educate diabetic beneficiaries and diabetic beneficiaries family members
f. Deliver Medical Nutrition Therapy
g. Maintain the beneficiary's or family's existing health and overall well-being
h. Provide personal, social, recreational, and general support services may be valuable adjuncts to care; however, they are not psychological interventions.
6. Health and Behavioral Assessment/Intervention (CPT codes 96150-96154) may only be performed by a Clinical Psychologist (CP Specialty Code 68).
7. Health and Behavioral Assessment/Intervention (CPT codes 96150-96154) may not be billed by physicians or non-physician practitioners (example: medical doctor, nurse practitioner, physician assistant, clinical nurse practitioner) or clinical social worker services.
8. Biofeedback as a behavioral modification technique will be limited to those indications recognized under the national coverage determination (30.1, publication 100-3,
http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx(external link)
Examples of services that are not considered part of Health and Behavioral Intervention services are:
Stress management for support staff
Replacement for expected nursing home staff functions
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 or caffeine withdrawal support
Visits for loneliness relief
Sensory stimulation
Games, including bingo games
Project, including letter writing
Entertainment
Excursions, including shopping outing, even when used to reduce a dysphoric state
Teaching grooming skills
Grooming services
Monitoring activities of daily living
Teaching the beneficiary simple self-care
Teaching the beneficiary to follow simple directives
Wheeling the beneficiary around the facility
Orienting the beneficiary 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 beneficiary care plans
Maintenance of behavioral logs
Coding Information
Bill Type Codes:
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:
CPT/HCPCS Codes
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.
| 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
Note: ICD-9 codes must be coded to the highest level of specificity.
| XX000 | Not Applicable |
Diagnoses that Support Medical Necessity
Medical diagnoses only
ICD-9 Codes that DO NOT Support Medical Necessity
| 290.0 - 290.9 | SENILE DEMENTIA UNCOMPLICATED - UNSPECIFIED SENILE PSYCHOTIC CONDITION |
| 291.0 - 291.9 | ALCOHOL WITHDRAWAL DELIRIUM - UNSPECIFIED ALCOHOL-INDUCED MENTAL DISORDERS |
| 292.0 - 292.9 | DRUG WITHDRAWAL - UNSPECIFIED DRUG-INDUCED MENTAL DISORDER |
| 293.0 - 293.9 | DELIRIUM DUE TO CONDITIONS CLASSIFIED ELSEWHERE - UNSPECIFIED TRANSIENT MENTAL DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE |
| 294.0 - 294.9 | AMNESTIC DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE - UNSPECIFIED PERSISTENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED ELSEWHERE |
| 295.00 - 295.95 | SIMPLE TYPE SCHIZOPHRENIA UNSPECIFIED STATE - UNSPECIFIED TYPE SCHIZOPHRENIA IN REMISSION |
| 296.00 - 296.99 | BIPOLAR I DISORDER, SINGLE MANIC EPISODE, UNSPECIFIED - OTHER SPECIFIED EPISODIC MOOD DISORDER |
| 297.0 - 297.9 | PARANOID STATE SIMPLE - UNSPECIFIED PARANOID STATE |
| 298.0 - 298.9 | DEPRESSIVE TYPE PSYCHOSIS - UNSPECIFIED PSYCHOSIS |
| 299.00 - 299.91 | AUTISTIC DISORDER, CURRENT OR ACTIVE STATE - UNSPECIFIED PERVASIVE DEVELOPMENTAL DISORDER, RESIDUAL STATE |
| 300.00 - 300.9 | ANXIETY STATE UNSPECIFIED - UNSPECIFIED NONPSYCHOTIC MENTAL DISORDER |
| 301.0 - 301.9 | PARANOID PERSONALITY DISORDER - UNSPECIFIED PERSONALITY DISORDER |
| 302.0 - 302.9 | EGO-DYSTONIC SEXUAL ORIENTATION - UNSPECIFIED PSYCHOSEXUAL DISORDER |
| 303.00 - 303.93 | ACUTE ALCOHOLIC INTOXICATION IN ALCOHOLISM UNSPECIFIED DRINKING BEHAVIOR - OTHER AND UNSPECIFIED ALCOHOL DEPENDENCE IN REMISSION |
| 304.00 - 304.93 | OPIOID TYPE DEPENDENCE UNSPECIFIED USE - UNSPECIFIED DRUG DEPENDENCE IN REMISSION |
| 305.00 - 305.93 | NONDEPENDENT ALCOHOL ABUSE UNSPECIFIED DRINKING BEHAVIOR - NONDEPENDENT OTHER MIXED OR UNSPECIFIED DRUG ABUSE IN REMISSION |
| 306.0 - 306.9 | MUSCULOSKELETAL MALFUNCTION ARISING FROM MENTAL FACTORS - UNSPECIFIED PSYCHOPHYSIOLOGICAL MALFUNCTION |
| 307.0 - 307.9 | ADULT ONSET FLUENCY DISORDER - OTHER AND UNSPECIFIED SPECIAL SYMPTOMS OR SYNDROMES NOT ELSEWHERE CLASSIFIED |
| 308.0 - 308.9 | PREDOMINANT DISTURBANCE OF EMOTIONS - UNSPECIFIED ACUTE REACTION TO STRESS |
| 309.0 - 309.9 | ADJUSTMENT DISORDER WITH DEPRESSED MOOD - UNSPECIFIED ADJUSTMENT REACTION |
| 310.0 - 310.9 | FRONTAL LOBE SYNDROME - UNSPECIFIED NONPSYCHOTIC MENTAL DISORDER FOLLOWING ORGANIC BRAIN DAMAGE |
| 311 | DEPRESSIVE DISORDER NOT ELSEWHERE CLASSIFIED |
| 312.00 - 312.9 | UNDERSOCIALIZED CONDUCT DISORDER AGGRESSIVE TYPE UNSPECIFIED DEGREE - UNSPECIFIED DISTURBANCE OF CONDUCT |
| 313.0 - 313.9 | OVERANXIOUS DISORDER SPECIFIC TO CHILDHOOD AND ADOLESCENCE - UNSPECIFIED EMOTIONAL DISTURBANCE OF CHILDHOOD OR ADOLESCENCE |
| 314.00 - 314.9 | ATTENTION DEFICIT DISORDER OF CHILDHOOD WITHOUT HYPERACTIVITY - UNSPECIFIED HYPERKINETIC SYNDROME OF CHILDHOOD |
| 315.00 - 315.9 | DEVELOPMENTAL READING DISORDER UNSPECIFIED - UNSPECIFIED DELAY IN DEVELOPMENT |
| 316 | PSYCHIC FACTORS ASSOCIATED WITH DISEASES CLASSIFIED ELSEWHERE |
| 317 | MILD MENTAL RETARDATION |
| 318.0 - 318.2 | MODERATE MENTAL RETARDATION - PROFOUND MENTAL RETARDATION |
| 319 | UNSPECIFIED MENTAL RETARDATION |
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
General Information
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 addresses.
Documentation in the medical record by the Clinical Psychologist (Specialty Code 68), must include:
1. Evidence of a referral, for the initial assessment and for each reassessment, to the Clinical Psychologist by the medical provider responsible for the medical management of the beneficiary's physical illness.
2. Evidence of coordination of care with the beneficiary'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.
3. The diagnosis (ICD-9 CM code) that reflect the condition of the beneficiary, and indicate the reason(s) for which the service was performed
4. Initial assessment (CPT code 96150) documentation in the medical record by the Clinical Psychologist must include evidence to support that the assessment is reasonable and necessary, and must include, at a minimum, the following elements:
a. Date of initial diagnosis of physical illness, and
b. Clear rationale for why assessment is required, and
c. Assessment outcome including mental status and ability to understand and to respond meaningfully, and
d. Goals and expected duration of specific psychological intervention(s), if recommended
5. Reassessment (CPT code 96151) documented must include the following elements:
a. Date of change in mental or physical status
b. Clear rationale for why re-assessment is required, and
c. Clear indication of the precipitating event that necessitates re-assessment
6. Intervention service, (CPT code 96152 96154) documentation to support that the intervention is reasonable and necessary must include, at a minimum, the following elements:
a. Evidence that the beneficiary has the capacity to understand and to respond meaningfully, and
b. Clearly defined psychological intervention plan and goals, and
c. The goals of the psychological intervention should clearly state how the psychological intervention is expected to improve compliance with the medical treatment plan, and
d. The response to the intervention must be indicated, and
e. Rationale for frequency and duration of services
7. The time duration (stated in minutes) for each visit spent in the health and behavioral assessment or intervention encounter.
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
Documentation in the medical record by the Clinical Psychologist (Specialty Code 68), must include:
1. Evidence of a referral, for the initial assessment and for each reassessment, to the Clinical Psychologist by the medical provider responsible for the medical management of the beneficiary's physical illness.
2. Evidence of coordination of care with the beneficiary'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.
3. The diagnosis (ICD-9 CM code) that reflect the condition of the beneficiary, and indicate the reason(s) for which the service was performed
4. Initial assessment (CPT code 96150) documentation in the medical record by the Clinical Psychologist must include evidence to support that the assessment is reasonable and necessary, and must include, at a minimum, the following elements:
a. Date of initial diagnosis of physical illness, and
b. Clear rationale for why assessment is required, and
c. Assessment outcome including mental status and ability to understand and to respond meaningfully, and
d. Goals and expected duration of specific psychological intervention(s), if recommended
5. Reassessment (CPT code 96151) documented must include the following elements:
a. Date of change in mental or physical status
b. Clear rationale for why re-assessment is required, and
c. Clear indication of the precipitating event that necessitates re-assessment
6. Intervention service, (CPT code 96152 96154) documentation to support that the intervention is reasonable and necessary must include, at a minimum, the following elements:
a. Evidence that the beneficiary has the capacity to understand and to respond meaningfully, and
b. Clearly defined psychological intervention plan and goals, and
c. The goals of the psychological intervention should clearly state how the psychological intervention is expected to improve compliance with the medical treatment plan, and
d. The response to the intervention must be indicated, and
e. Rationale for frequency and duration of services
7. The time duration (stated in minutes) for each visit spent in the health and behavioral assessment or intervention encounter.
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.
The initial service (CPT code 96150) is limited to one visit (maximum of one hour/four 15-minute services) regardless of the number of sessions it takes to complete the initial assessment.
It is expected that the Health and Behavior Assessment/Intervention services will be performed in a health care facility or the provider's office.
Other Comments:
This policy does not reflect the sole opinion of the contractor or the Contractor Medical Director(s). Although the final decision rests with the contractor, this policy was developed in cooperation with the Carrier Advisory Committee(s), which include representatives of various medical specialty societies.
Sources of Information and Basis for Decision
It is expected that the Health and Behavior Assessment/Intervention services will be performed in a health care facility or the provider's office.
Other Comments:
This policy does not reflect the sole opinion of the contractor or the Contractor Medical Director(s). Although the final decision rests with the contractor, this policy was developed in cooperation with the Carrier Advisory Committee(s), which include representatives of various medical specialty societies.
Program Memorandum, Expanded Coverage of Diabetes Outpatient Self-Management Training, CR 1455, June 15, 2001
Program Memorandum, Medical Nutrition Therapy for Beneficiaries with Diabetes or Renal Disease, CR 1776, August 7, 2001
Daw, Jennifer, Monitor On Psychology, "Bucking the System", January 2002, pages 68-69.
CPT Changes, "An Insider 's View", 2002, American Medical Association, pages 218-220.
CFR Title 42, Part 410.73(b)(1)
This section specifies the services of a clinical social worker are limited to the diagnosis and treatment of mental illness.
CPT Assistant March 02:4, February 04:11, March 04:10
Advisory Committee Meeting Notes
Program Memorandum, Medical Nutrition Therapy for Beneficiaries with Diabetes or Renal Disease, CR 1776, August 7, 2001
Daw, Jennifer, Monitor On Psychology, "Bucking the System", January 2002, pages 68-69.
CPT Changes, "An Insider 's View", 2002, American Medical Association, pages 218-220.
CFR Title 42, Part 410.73(b)(1)
This section specifies the services of a clinical social worker are limited to the diagnosis and treatment of mental illness.
CPT Assistant March 02:4, February 04:11, March 04:10
Meeting Date:
Wisconsin: 09/25/2009
Illinois: 09/16/2009
Michigan: 09/09/2009
Minnesota: 09/24/2009
Iowa, Kansas, Missouri, Nebraska 10/08/2009
Open Meeting: 08/19/2009
Start Date of Comment Period
Wisconsin: 09/25/2009
Illinois: 09/16/2009
Michigan: 09/09/2009
Minnesota: 09/24/2009
Iowa, Kansas, Missouri, Nebraska 10/08/2009
Open Meeting: 08/19/2009
10/08/2009
End Date of Comment Period
11/23/2009
Start Date of Notice Period
02/01/2010
Revision History Number
X
Revision History Explanation
04/06/2010 -NO Revision to Policy, Inserted verbage that was originally omitted from Idications and Limitations Section of Policy. (DK)
04/19/2010 In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of American Somoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands were removed from this LCD because claims processing for those states are transitioning from FI Contractor Wisconsin Physician Services (WPS - 52280) to MAC Part A Contractor Palmetto.
09/06/2010 - This policy was updated by the ICD-9 2010-2011 Annual Update.
10/18/2010 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Colorado, New Mexico, Oklahoma and Texas were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Trailblazers (04901).
11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
96150 descriptor was changed in Group 1
96151 descriptor was changed in Group 1
96152 descriptor was changed in Group 1
96153 descriptor was changed in Group 1
96154 descriptor was changed in Group 1
02/21/2011 In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).
03/01/2011, one, reviewed, no update needed
Reason for Change
04/19/2010 In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of American Somoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands were removed from this LCD because claims processing for those states are transitioning from FI Contractor Wisconsin Physician Services (WPS - 52280) to MAC Part A Contractor Palmetto.
09/06/2010 - This policy was updated by the ICD-9 2010-2011 Annual Update.
10/18/2010 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Colorado, New Mexico, Oklahoma and Texas were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Trailblazers (04901).
11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
96150 descriptor was changed in Group 1
96151 descriptor was changed in Group 1
96152 descriptor was changed in Group 1
96153 descriptor was changed in Group 1
96154 descriptor was changed in Group 1
02/21/2011 In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).
03/01/2011, one, reviewed, no update needed
03/01/2011
Related Documents
This LCD has no Related Documents.
LCD Attachments
Coding and Billing Guidelines - Version 1 (PDF - 20,179 bytes )
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Page Last Updated: Wednesday, 05-Oct-2011 15:06:23 CDT
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