Psychologists now have a more accurate, refined way of billing for services provided to patients with a physical health diagnosis, thanks to the advent of six new reimbursement codes under the Current Procedural Terminology (CPT) coding system.
As of January 1, 2002, codes for health and behavior assessment and intervention services now apply to behavioral, social, and psychophysiological procedures for the prevention, treatment or management of physical health problems. Developing these new codes involved the combined efforts of the APA’s Practice Directorate and the Interdivisional Healthcare Committee (IHC), representing APA divisions 17, 22, 38, 40 and 54. This constitutes a milestone in the recognition of psychologists as health care providers.
The health and behavior assessment and intervention codes 96150 the initial assessment of the patient to determine the biological, psychological, and social factors affecting the patient’s physical health and any treatment problems.
96151 a re-assessment of the patient to evaluate the patient’s condition and determine the need for further treatment. A re-assessment may be performed by a clinician other than the one who conducted the patient’s initial assessment.
96152 the intervention service provided to an individual to modify the psychological, behavioral, cognitive, and social factors affecting the patient’s physical health and well being. Examples include increasing the patient’s awareness about his or her disease and using cognitive and behavioral approaches to initiate physician prescribed diet and exercise regimens.
96153 the intervention service provided to a group. An example is a smoking cessation program that includes educational information, cognitive-behavioral treatment and social support. Group sessions typically last for 90 minutes and involve 8 to 10 patients.
96154 the intervention service provided to a family with the patient present. For example, a psychologist could use relaxation techniques with both a diabetic child and his or her parents to reduce the child’s fear of receiving injections and the parents’ tension when administering the injections.
96155 the intervention service provided to a family without the patient present. An example would be working with parents and siblings to shape the diabetic child’s behavior, such as praising successful diabetes management behaviors and ignoring disruptive tactics.
How these services differ from psychotherapy
Until now, almost all intervention codes used by psychologists involved psychotherapy and required a mental health diagnosis, such as under the DSM-IV. In contrast, health and behavior assessment and intervention services focus on patients whose primary diagnosis is physical in nature.
The codes capture services addressing a wide range of physical health issues, such as patient adherence to medical treatment, symptom management, health-promoting behaviors, health-related risk-taking behaviors, and overall adjustment to physical illness. In almost all of these cases a physician will already have diagnosed the patient’s physical health problem. Physical health diagnoses are typically represented by ICD-9 CM codes (see www.cdc.gov/nchs/icd9.htm ).
If a psychologist is treating a patient with both a physical and mental illness he or she must pay careful attention to how each service is billed. The health and behavior codes cannot be used for psychotherapy services addressing the patient’s mental health diagnosis nor can they be billed on the same day as a psychiatric CPT code. The psychologist must report the predominant service performed.
Use of the codes will enable reimbursement for the delivery of psychological services for an individual whose problem is a physical illness and does not have a mental health diagnosis. Since these codes are new, reimbursement rates from the private sector have not been determined. However, it is important that psychologists begin to use these codes now to accurately capture the services provided.
New codes to be paid with physical health dollars in Medicare
When providing outpatient care to Medicare beneficiaries, services for these patients will be reimbursed at a higher rate than psychotherapy because under current Federal regulations, the outpatient mental health treatment limitation does not apply to these new services (it only applies to services provided to patients with a mental, psychoneurotic, or personality disorder identified by an ICD-9 CM diagnosis code between 290 and 319). For example, Medicare would reduce the approved amount of a 45-minute outpatient psychotherapy session by 62.5% and then reimburse 80% of the remainder, resulting in a payment of approximately $48. In contrast, Medicare would reimburse a 45-minute outpatient health and behavior intervention for an individual at 80% of the approved amount, or approximately $59.
Federal reimbursement for the health and behavior assessment and intervention codes will come out of funding for medical rather than psychiatric services and will not draw from limited mental health dollars. For private third party insurance we expect these services to be treated under the physical illness benefits of a plan and thus not be subjected to the higher outpatient consumer co-payment found in Medicare or relegated to behavioral health “carve out” provisions.
Estimated Medicare reimbursement rates
The codes and their assigned relative values used for calculating Medicare fees are listed in the 2002 physician fee schedule issued by the Centers for Medicare and Medicaid Services (CMS) in the November 1, 2001 Federal Register. Each code is based on 15 minutes of service so a psychologist would bill 2 units when providing a 30-minute service. When the service falls between units you must round up or down to the nearest increment. To illustrate, a psychologist would bill 3 units for a 50-minute service but would bill 4 units for a 55-minute service.
Illustrated below are estimated Medicare reimbursement amounts for 2002. Psychologists should check with their local Medicare carriers for the exact payment rates in their geographic area.
CPT Code Service Approximate Medicare Payment (15 min 1 unit) (1 hr 4units)
96150 Assessment initial $ 26 * $ 106 *
96151 Re-assessment $ 26 $ 103
96152 Intervention individual $ 25 $ 98
96153 Intervention group (per person) $ 5 ** $ 22 **
96154 Intervention family w/ patient $ 24 $ 96 96155 Intervention family w/o patient $ 23 $ 93
* Multiple-unit differences are due to rounding ** Total group fee equals amount times number of persons in group
qEEG CPT Coding
Additional Questions
The Practice Directorate has continued to receive many questions about implementation of the new CPT codes. This material was prepared in an effort to address the most frequently asked questions. Should you have further questions, please contact Diane Pedulla or Steve McEllin in Government Relations at (202) 336-5889.