by Government Relations Staff
April 12, 2012 — Practicing psychologists are eligible to bill for applicable services and receive reimbursement from Medicare and many private insurance carriers using "health and behavior assessment and intervention" Current Procedural Terminology (CPT)® codes (H & B codes). These codes apply to psychological services that address behavioral, social, and psychophysiological conditions in the treatment or management of patients diagnosed with physical health problems. The Practice Directorate and other key American Psychological Association (APA) representatives developed and won inclusion of the H & B codes in the CPT manual.
The following material, including Medicare's national reimbursement amounts for 2012, is part of a detailed question-and-answer guide first released in 2009 about the H & B codes that addresses frequent inquiries from APA members. The complete question-and-answer guide appears as a PDF at the end of this article.
What types of services are the health and behavior assessment and intervention codes used to describe?
The use of these CPT codes requires a physical health diagnosis. Typically, health and behavior assessment and intervention services address an assortment of physical health issues — including patient adherence to medical treatment, symptom management, health-promoting behaviors, health-related risk-taking behaviors and overall adjustment to physical illness.
Can I provide health and behavior services to patients diagnosed with a physical health problem who also have been diagnosed with a mental health problem?
Yes, being diagnosed with a mental health disorder does not preclude a patient from being eligible to receive health and behavior services to address a diagnosed physical health problem.
Can I bill the health and behavior CPT codes to both Medicare and private insurance carriers?
Medicare reimburses for five out of the six codes, with the exception of 96155 (family intervention without the patient present). Some private health insurance plans have begun to pay for these codes as well. Private insurance plans may have payment policies that are more or less restrictive than under Medicare. Psychologists should check with the private insurer about a plan's payment policies regarding these codes.
What are the 2012 national Medicare reimbursement rates for these codes?
The codes and their assigned values are listed in the physician fee schedule issued by the Centers for Medicare and Medicaid Services (CMS) and published in the Federal Register. Each code is based on 15 minutes of service. For example, psychologists would bill two units when providing a 30-minute service and four units for a one-hour service.
Below are estimated national reimbursement amounts for 2012. These national rates are subject to a geographic adjustment. Psychologists should check with their local Medicare Administrative Contractor (MAC) for the exact payment rate in their geographic area.
CPT Code: 96150
Service: Assessment-Initial
2012 National Medicare payment for 15 min (1 unit): $20.42
2012 National Medicare payment for 1 hour (4 units): $81.68
CPT Code: 96151
Service: Re-Assessment
2012 National Medicare payment for 15 min (1 unit): $19.74
2012 National Medicare payment for 1 hour (4 units): $78.96
CPT Code: 96152
Service: Intervention-Individual
2012 National Medicare payment for 15 min (1 unit): $18.72
2012 National Medicare payment for 1 hour (4 units): $74.88
CPT Code: 96153
Service: Intervention - Group (per person)*
2012 National Medicare payment for 15 min (1 unit): $4.42
2012 National Medicare payment for 1 hour (4 units): $17.68
CPT Code: 96154
Service: Intervention - Family with patient
2012 National Medicare payment for 15 min (1 unit): $18.38
2012 National Medicare payment for 1 hour (4 units): $73.52
CPT Code: 96155
Service: Intervention - Family without patient
Medicare does not pay for this H&B code.
* Total group fee equals the amount multiplied by the number of persons in the group
Can a DSM-IV diagnosis code be used in conjunction with these services?
No, only an ICD-9-CM physical diagnosis code should be used in connection with these services. A physical diagnosis code applies since health and behavior assessment and intervention services focus on patients whose primary diagnosis is a physical health problem.
Does the Medicare "Outpatient Mental Health Treatment Limitation" apply to services provided under the codes?
No, the Outpatient Mental Health Treatment Limitation applies only to services provided to outpatients with a mental, psychoneurotic or personality disorder identified by an ICD-9-CM diagnosis code between 290 and 319. Health and behavior assessment and intervention services provided to outpatients are reimbursed at 80 percent.
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Current Procedural Terminology (CPT)® copyright 2012. American Medical Association. All Rights Reserved.