Article - Health and Behavior Assessment/Intervention – Medical Policy Article (A52434)

CMS National Coverage PolicyN/AArticle TextAbstract:"Health and Behavior Assessmentprocedures 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 of the assessment is not on mental health but on the biopsychosocial factors important to physical health problems and treatments."1Health and Behavior Interventionprocedures are used to modify the psychological, behavioral, emotional, cognitive, and social factors directly affecting the patient's physiological functioning, health and well being, or specific disease-related problems.Health Behavior Assessment and Intervention (HBAI) services described by CPT codes 96156, 96158, 96159, 96164, 96165, 96167, and 96168, and any successor codes, are billed by clinical social workers, marriage and family therapists (MFTs), and mental health counselors (MHCs), in addition to clinical psychologists.Indications:The Health and Behavioral Assessment, initialand Reassessment and Intervention services may be considered reasonable and necessary for the patient who meetsallof the following criteria:The patient has an underlying physical illness or injury, andThere are indications that biopsychosocial factors may be significantly affecting the treatment or medical management of an illness or an injury, andThe patient is alert, oriented and has the capacity to understand and to respond meaningfully during the face-to-face encounter, andThe patient has a documented need for psychological evaluation or intervention to successfully manage his/her physical illness, and activities of daily living, andThe assessment is not duplicative of other provider assessmentsIn addition, for a reassessment to be considered reasonable and necessary, there must be documentation that there has been a sufficient change in the mental or medical status warranting re-evaluation of the patient's capacity to understand and cooperate with the medical interventions necessary to their health and well being.Health and Behavioral Intervention, individual or group (2 or more patients)require that:Specific psychological intervention(s) and patient outcome goal(s) have been clearly identified, andPsychological intervention is necessary to address:Non-compliance with the medical treatment plan, orThe 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.Health and Behavioral Intervention (with the family and patient present)is considered reasonable and necessary for the patient who meets all of the following criteria:The family representative* directly participates in the overall care of the patient, andThe 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, health-related risk-taking behaviors, and overall adjustment to medical illness.*For the purpose of this policy, all references to a family representative is defined as immediate family members only (i.e., husband, wife, siblings, children, grandchildren, grandparents, mother, and father), any primary caregiver who provides care on a voluntary, uncompensated, regular and sustained basis, or a guardian or healthcare proxy.Limitations:Health and Behavioral Assessment/Intervention will not be considered reasonable and necessary for the patient who:Does not have an underlying physical illness or injury, orFor whom there is no documented indication that a biopsychosocial factor may be significantly affecting the treatment, or medical management of an illness or injury (i.e., screening medical patient for psychological problems), orDoes 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.DeliriumSevere and profound mental retardationPersistent vegetative state/no discernible consciousness,Impaired mental status, e.g.,disorientation to person, time, place, purpose, orinability to recall current season, location of own room, names and faces, orinability to recall that he or she is in a nursing home or skilled nursing facilityDoes 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, orFor whom the conditions noted under the indications portion of this section are not met.Health and Behavioral Intervention with the family and patient present will not be considered reasonable and necessary for the patient if:It is not necessary to ensure patient compliance with the medical treatment plan, orThe family representative does not directly participate in the plan of care, orThe family representative is not present.There is no face to face encounter with the patient.Because it does not represent a diagnostic or treatment service to the patient, there is no coverage for CPT codes 96170, 96171.Health and Behavioral Intervention services are not considered reasonable and necessary to:Update or educate the family about the patient's conditionEducate family members, primary care-givers, guardians, the health care proxy, or 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.Assist in treatment-planning with staffProvide family psychotherapy or mediationEducate diabetic patients and diabetic patients' family membersDeliver Medical Nutrition TherapyMaintain the patient's or family's existing health and overall well-beingProvide personal, social, recreational, and general support services. Although such services may be valuable adjuncts to care, they are not medically necessary psychological interventions.Examples of services not covered as health and behavioral interventions are:Stress management for support staffReplacement for expected nursing home staff functionsMusic appreciation and relaxationCraft skill trainingCooking classesComfort care servicesIndividual social activitiesTeaching social interaction skillsSocialization in a group settingRetraining cognition due to dementiaGeneral conversationServices directed toward making a more dynamic personalityConsciousness raisingVocational or religious adviceGeneral educational activitiesTobacco or caffeine withdrawal supportVisits for loneliness reliefSensory stimulationGames, including bingo gamesProjects, including letter writingEntertainment and diversionary activitiesExcursions, including shopping outings, even when used to reduce a dysphoric stateTeaching grooming skillsGrooming servicesMonitoring activities of daily livingTeaching the patient simple self-careTeaching the patient to follow simple directivesWheeling the patient around the facilityOrienting the patient to name, date, and placeExercise programs, even when designed to reduce a dysphoric stateMemory enhancement trainingWeight loss managementCase management services including but not limited to planning activities of daily living, arranging care or excursions, or resolving insurance problemsActivities principally for diversionPlanning for milieu modificationsContributions to patient care plansMaintenance of behavioral logsBiofeedback is coded as 90901 and will not be covered as a health and behavioral intervention.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must describe the patient's condition for which the service was performed.Advance Beneficiary Notice of Noncoverage (ABN) Modifier GuidelinesAn ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04,Medicare Claims Processing Manual,Chapter 30, for complete instructions.If the initial health and behavior assessment or reassessment is unable to be completed during a single encounter, the date of service indicated on the claim should be the date on which the interview was finalized.For health and behavior assessment and/or intervention services performed by a physician, clinical nurse specialist (CNS), or nurse practitioner (NP), Evaluation and Management (E&M) or Preventive Medicine services codes should be used.Services to patients for evaluation and treatment of mental illnesses should be coded using a psychiatric services CPT code (90801-90899).For patients that require psychiatric services (CPT codes 90801-90899) as well as health and behavior assessment/intervention (96156, 96167, 96168), report the predominant service performed.The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. Claims submitted without ICD-10-CM codes will be returned.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.Documentation in the medical record must include:a. For the initial assessment, evidence to support that the assessment is reasonable and necessary, and must include, at a minimum, the following elements:Date of initial diagnosis of physical illness, andClear rationale for why assessment is required, andAssessment outcome including mental status and ability to understand and respond meaningfully, andGoals and expected duration of specific psychological intervention(s), if recommended.b.For re-assessment, detailed progress notes to support that the reassessment is reasonable and necessary must include the following elements:Date of change in mental or physical statusSufficient rationale for why re-assessment is required, and,Clear indication of any precipitating events that necessitate re-assessmentc. 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 and to respond meaningfullyClearly defined psychological intervention plannedThe goals of the psychological interventionThe expectation that the psychological intervention will improve compliance with the medical treatment planThe response to the interventionRationale for frequency and duration of servicesFor all claims, the time duration (stated in minutes) spent in the health and behavioral assessment or intervention encounter must be documented in the record.Documentation must be available to Medicare upon request.Sources of Information:This bibliography presents those sources that were obtained during the development of this policy. National Government Services is not responsible for the continuing viability of Web site addresses listed below.Current Procedural Terminology, CPT 2009Program Memorandum, Expanded Coverage of Diabetes Outpatient Self-Management Training, CR 1455, June 15, 2001Program Memorandum, Medical Nutrition Therapy for Beneficiaries with Diabetes or Renal Disease, CR 1776, August 7, 2001Carrier Advisory Committee Psychiatry Working GroupCPT Changes,"An Insider's View", 2002, American Medical Association, pages 218-220.