Health and Behavior CPT® Codes

by Government Relations Staff

Article reviewed for accuracy March 2018

February 2004 — 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 Jan. 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 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.

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 reassessment of the patient to evaluate the patient's condition and determine the need for further treatment. A reassessment 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.

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. 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.

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-10 CM codes (see the CDC website).

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 (90785-90899). The psychologist must report the predominant service performed.

The codes and their assigned relative values used for calculating Medicare fees are listed in the physician fee schedule issued by the Centers for Medicare and Medicaid Services (CMS) each November in the Federal Register. Each code is based on 15 minutes of service, so a psychologist would bill two 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 three units for a 50-minute service but would bill four units for a 55-minute service.

Illustrated below are estimated Medicare reimbursement amounts. Psychologists should check with their local Medicare Administrative Contractor (MAC) for the exact payment rates in their geographic area.

* Multiple-unit differences are due to rounding.
** Total group fee equals amount times number of persons in group.

Current Procedural Terminology^© 2018 American Medical Association. All Rights Reserved. Article updated March 2018