documentation requirements for cpt code 96160

You can use your browser's Print function (Ctrl-P on a PC or Command-P on a Mac) to view a print preview and then select PDF as the output. These patients may have a family history of certain diseases, exhibit risk factors such as obesity or smoking, or have a history of exposure to environmental hazards. 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Please review and accept the agreements in order to view Medicare Coverage documents, which may include licensed information and codes. In other words, HRAs identify patients modifiable health risks, which then allows a pediatrician to then provide follow-up behavior change interventions and improve health outcomes, according to the Centers for Disease Control and Prevention (CDC) (Source: https://www.cdc.gov/policy/hst/HRA/FrameworkForHRA.pdf). The patients responses to the questionnaire. The physician reports code 99392 for the preventive service and two units of code 96110 for the administration of the structured screening instruments. Please contact the Medicare Administrative Contractor (MAC) who owns the document. Enter the code you're looking for in the "Enter keyword, code, or document ID" box. You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement. Clarification was made to the Health and behavioral assessment and Health and behavioral intervention. A healthcare provider administers a cardiovascular risk assessment questionnaire to a patient with a family history of heart disease. All other Codes (ICD-10, Bill Type, and Revenue) have moved to Articles for DME MACs, as they have for the other Local Coverage MAC types. Please do not use this feature to contact CMS. For this supplementary claims processing information we rely on other CMS publications, namely Change Requests (CR) Transmittals and inclusions in the Medicare Fee-For-Service Claims Processing Manual (CPM). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient. The instrument is scorable. An asterisk (*) indicates a . In order for CMS to change billing and claims processing systems to accommodate the coverage conditions within the NCD, we instruct contractors and system maintainers to modify the claims processing systems at the national or local level through CR Transmittals. (You may have to accept the AMA License Agreement.) CPT 96160 was added to the Current Procedural Terminology system on January 1, 2017. Please contact your Medicare Administrative Contractor (MAC). The document is broken into multiple sections. 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Absence of a Bill Type does not guarantee that the For re-assessment, detailed progress notes must include the following elements: Date of change in mental or physical status, Clear rationale for why re-assessment is required, Clear indication of the precipitating event that necessitates re-assessment, and, Changes in goals, duration and/or frequency and duration of services. CPT 96160 is a code used for the administration of patient-focused health risk assessment instruments, including scoring and documentation. However, code 96127 should be reported for both screening and follow-up of emotional and behavioral health conditions. required field. CMS has defined "not usually self-administered" according to how the Medicare population as a whole uses the drug, not how an individual patient or physician may choose to use a particular drug. Applications are available at the American Dental Association web site. Coding Alert 3: Some payers require reporting 96160 for depression screening other than postpartum depression, even though 96127 is intended for reporting this service, Hughes adds. You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. CPT code 96150 : Health and behavior initial assessment, each 15 minutes face-to-face with the patient CPT code 96151 : Health and behavior re-assessment, each 15 minutes face-to-face with the patient Deleted H&B Assessment Services (Effective 1/1/2020) 6 The patient expresses a feeling of hopelessness related to relationships lost during opioid use and sexuality issues. 25 Self-Administered Drug (SAD) Exclusion List articles list the CPT/HCPCS codes that are excluded from coverage under this category. copied without the express written consent of the AHA. For instance, one plan in Tennessee has paid between $150 and $250 for code 96160 when a specific HRA is completed in conjunction with the IPPE or AWV. Disclaimer: The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. Please Note: For Durable Medical Equipment (DME) MACs only, CPT/HCPCS codes remain located in LCDs. *7. While every effort has been made to provide accurate and The AMA does not directly or indirectly practice medicine or dispense medical services. These codes do not represent physician work. When reporting CPT codes 96159, 96165, and 96168, the quantity billed should reflect 1 unit for each 15 minutes. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. This article is being retired effective for dates of service on and after 12/08/2022 because the related LCD is being retired. The requirements to report either 96160 or 96161 are as follows: Practice expense is incurred to administer the instrument (such as nurse time or for purchase of the screen). A healthcare provider administers a nutrition risk assessment questionnaire to a patient with a history of poor dietary habits. Evidence of a referral to the Clinical Psychologist by the medical provider responsible for the medical management of the patients physical illness or verification of a recommendation from the medical provider to the Clinical Psychologist, obtained by request and review of the permanent medical record, must be documented in the medical record for the initial assessment and for reassessment. Many Medic-aid plans have adopted code 96161 for screening for postpartum depression at well-baby visits (some may allow up to six screenings before the child is 13 months old). Modifier 33 may be required to indicate a service that may be preventive or diagnostic was provided as a preventive service. You should not bill 96160 separately when the service is explicitly included in another service being furnished, such as the Medicare AWV. "JavaScript" disabled. What Counts as a Standardized Instrument? All comments are moderated and will be removed if they violate ourTerms of Use. Documentation of a structured screening or assessment should include the date, patient's name, name and relationship of the informant (when information is provided by someone other than the patient), name of the instrument, score, and name and credentials of the individual administering the instrument. This test is performed using an electronic platform, such as a computer, and the results of the test are automatically generated. article does not apply to that Bill Type. You must know your specific payer policies. Here are some hints to help you find more information: 1) Check out the Beneficiary card on the MCD Search page. Billing and Coding articles typically include CPT/HCPCS procedure codes, ICD-10-CM diagnosis codes, as well as Bill Type, Revenue, and CPT/HCPCS Modifier codes. Codes 96110, 96160, and 96161 are typically limited to developmental screening and the health risk assessment (HRA). However, if the physician diagnoses depression, you may report it separately since the global package was valued for uncomplicated antepartum, delivery, and postpartum care. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be In this article, we will review the documentation and billing requirements necessary for getting paid. For payment purposes, each screening and assessment code was valued based on practice expense and professional liability only, which includes the cost of furnishing instruments (when applicable) and staff time to administer and/or score an instrument for the physician or other qualified health care professional's review. Refer to the current HCPG for examples of other scientifically validated screening tools for adolescent health risk. Clinical staff administer and score a structured screening instrument for depression with positive results. The code lists in the article help explain which services (procedures) the related LCD applies to, the diagnosis codes for which the service is covered, or for which the service is not considered reasonable and necessary and therefore not covered. So, 96110 and 96127 are used whenever your provider is assessing a patients psychological and neuropsychological condition, such as a patients memory, language, visual motor responses, and abstract reasoning/ problem-solving abilities, whereas 96160/96161 are used whenever your provider is assessing how a psychological condition is impacting a patients health condition (96160) or how the patients caregivers psychological condition may affect the caregivers ability to care for the patient (96161). HCPCS/CPT Codes. Coding Alert 2: If your pediatrician also provides an intervention for alcohol or substance abuse, you would report codes 99408 (Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes) and 99409 ( greater than 30 minutes) depending on time, Hughes cautions. CPT is a trademark of the American Medical Association (AMA). Related policy n/a References Center for Disease Control and Prevention (CDC). that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes. recipient email address(es) you enter. Physicians should check with their specific payers. Medicaid plans often allow payment for adolescent HRAs using tools such as the HEE-ADSSS (Home, Education, Eating, Activities, Drugs, Sexuality, Suicide/Depression, Safety) assessment or the CRAFFT (Care, Relax, Alone, Forget, Friends, Trouble) screening tool. All rights reserved. American College of Obstetricians and Gynecologists Getting Paid for Screening and Assessment Services. Report CPT code 90791 for the psychiatric diagnostic interview and G0396 indicating the performance of 15-30 minutes of SBIRT services. Adapted from Getting Paid for Screening and Assessment Services.. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. Please enable "JavaScript" and revisit this page or proceed with browsing CMS.gov with But some brief assessment instruments such as the Epworth Sleepiness Scale may be considered an HRA by some payers but bundled with a diagnostic E/M service by others, Hughes cautions. Diagnosis code Z00.129, Encounter for routine child health examination without abnormal findings, is linked to each service reported as this code includes an encounter for developmental screening. will not infringe on privately owned rights. Organizations who contract with CMS acknowledge that they may have a commercial CDT license with the ADA, and that use of CDT codes as permitted herein for the administration of CMS programs does not extend to any other programs or services the organization may administer and royalties dues for the use of the CDT codes are governed by their commercial license. Coding Alert 1: Some payers require reporting 96127 for HEEADSSS and CRAFFT screenings, Hughes notes. Applicable Federal Acquisition Regulation Clauses (FARS)/Department of Defense Federal Acquisition Regulation supplement (DFARS) Restrictions Apply to Government Use. Report the additional CPT code (99202-99205 and 99211-99215) with modifier -25. For more information, please visit ACOGs Solutions section (May 2015, Perinatal Depression). 6. Per CPT, standardized instruments are validated tests that are administered and scored in a consistent or standard manner consistent with their validation. For 96160, that would include such tests as the Mini Nutritional Assessment-Short Form; Sport Concussion Assessment Tool (SCAT 5-); Alcohol Use Disorders Identification Test; Care, Relax, Alone, Forget, Friends, Trouble (CRAFFT); and Home, Education, Eating, Activities, Drugs and Alcohol, Suicide and Depression Sexuality and Safety (HEEADSSS), while standardized tests appropriate for 96161 include the Safe Environment for Every Kid; Caregiver Strain Index; and Edinburgh Postnatal Depression Scale, according to Cindy Hughes, CPC, CFPC, consulting editor of Cindy Hughes Consulting in El Dorado, Kansas. National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits do not bundle 96160 and 96161 into the office/outpatient evaluation and management (E/M) codes 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient ) or the preventive medicine E/M codes 99381-99396 (Initial/periodic comprehensive preventive medicine evaluation/reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new/established patient ), and no CPT regulations prohibit the services from being reported together. The scope of this license is determined by the AMA, the copyright holder. This article will cover topics such as the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 96160 procedures. The purpose of the screening or assessment should guide code selection. Flexibility #6 17 18 2) Try using the MCD Search and enter your information in the "Enter keyword, code, or document ID" box. The Medicare program provides limited benefits for outpatient prescription drugs. If you are experiencing any technical issues related to the search, selecting the 'OK' button to reset the search data should resolve your issues. Medicare contractors are required to develop and disseminate Articles. The physician reports preventive medicine E/M code 99395 with ICD-10 code Z00.01, Routine adult medical examination with abnormal findings, and F32.1, Major depressive disorder, single episode, moderate. Also reported to the patient's health plan is code 96127 for the depression screening with ICD-10 diagnosis code Z13.89 Encounter for screening for other disorder. If a significant, separately identifiable E/M service was rendered for depression or another health problem, an established patient office or other outpatient service code would be separately reported with modifier 25 appended. A few payers do indicate that a report (separate from the E/M service documentation) is also required, so verify your payers' documentation requirements prior to providing these services. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential Some articles contain a large number of codes. This code is used when a healthcare provider administers a standardized questionnaire to a patient to help identify specific health risks, analyzes the results, assigns a score, and documents the findings. All documentation must be maintained in the patient's medical record and made available to the contractor upon request. A healthcare provider administers a skin cancer risk assessment questionnaire to a patient with a history of sunburns and tanning bed use. Are HRAs Bundled Into E/Ms or Other Services? Neither the United States Government nor its employees represent that use of such information, product, or processes A neuropsychologist is completing a neuropsychological evaluation. Alcohol and Substance Abuse Screening and Brief Intervention (i.e., CRAFFT) pg. Goals and expected duration of specific psychological intervention(s), if recommended. an effective method to share Articles that Medicare contractors develop. Some payers require reporting 96127 for HEEADSSS and CRAFFT screenings. Although an HRA is bundled in the AWV under Medicare Part B, code 96160 may be billed separately in Medicare Advantage plan quality initiatives. For purpose of this exclusion, "the term 'usually' means more than 50 percent of the time for all Medicare beneficiaries who use the drug. (Monday through Friday, 8:30 a.m. to 5 p.m. This procedure includes the administration of the questionnaire, documentation, and scoring. "JavaScript" disabled. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. Yes, a claim must be submitted with Current Procedural Terminology (CPT) code 96160 in conjunction and on the same claim with the appropriate office visit, evaluation and management code (E/M) or Annual Wellness Visit code indicating a face-to-face visit occurred. Who Is Covered. and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only Federal government websites often end in .gov or .mil. Code G0444 should be reported to Medicare Part B administrative contractors for this purpose instead of code 96127, and the time spent on screening and discussing results and recommendations should be documented. Try entering any of this type of information provided in your denial letter. How Do 96160/96161 Differ From Each Other? Though screening and assessment services require verification of benefits and of coding and documentation requirements, these services may be beneficial to both the patient and the practice. Although the fee-for-service payment for screening and assessments may be small, it can add up to significant income across a patient panel. Coding Alert 1: Some payers require reporting 96127 for HEEADSSS and CRAFFT screenings, Hughes notes. Child Development/Developmental Monitoring and Screening. 96160 Administration of patient-focused health risk assessment instrument (e.g., . Look for a Billing and Coding Article in the results and open it. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). For example, Aetna clearly encourages and pays for depression screening reported with code 96127 and ICD-10 code Z13.89, Encounter for screening for other disorder. Cigna has a national policy that provides separate coverage of developmental screening (96110), brief behavioral health assessment (96127), and depression screening reported with HCPCS code G0444. The healthcare provider selects an appropriate standardized health risk assessment instrument for the patient. Instrument-based assessment of potential emotional and/or behavioral problems (e.g., depression, attention-deficit), Patient Health Questionnaire-9, Edinburgh Postnatal Depression Scale (administered for the benefit of the mother), and NICHQ Vanderbilt Assessment Scales. Any questions pertaining to the license or use of the CPT should be addressed to the AMA. THE UNITED STATES In addition, the physician must document that he or she reviewed the score in the context of the patient presentation and discussed the results with the patient/family as part of the related E/M service. There are different article types: Articles are often related to an LCD, and the relationship can be seen in the "Associated Documents" section of the Article or the LCD. contact your MAC for guidance. For the most part, codes are no longer included in the LCD (policy). (Or, for DME MACs only, look for an LCD.) When 96160 and 96161 are column 1 codes to 96127 and 96110, NCCI considers the column 2 codes as components of the HRA services, though as NCCI assigns the PTP pairs modifier indicators of 1, the edits may be overridden with an NCCI-associated modifier when appropriate. The healthcare provider reviews the patients responses and analyzes the results. If you are not billing for these services, you may be losing out on valuable revenue. The HRA codes are subject to PTP edits when reported with the other screening and assessment codes, however. The HRA codes 96160 (Administration of patient-focused health risk assessment instrument [eg, health hazard appraisal] with scoring and documentation, per standardized instrument) and 96161 (Administration of caregiver-focused health risk assessment instrument [eg, depression inventory] for the benefit of the patient, with scoring and documentation, per standardized instrument) like all the health behavior assessment and intervention codes (96156-96161) are used to identify and address the psychological, behavioral, emotional, cognitive, and interpersonal factors important to the assessment, treatment, or management of physical health problems, according to CPT guidelines. NCDs do not contain claims processing information like diagnosis or procedure codes nor do they give instructions to the provider on how to bill Medicare for the service or item. End User License Agreement: ET), 2023 Annual Clinical & Scientific Meeting, Congressional Leadership Conference (CLC), Coding Question: Postpartum Depression Screening, Alliance for Innovation on Maternal Health, Postpartum Contraceptive Access Initiative. 409 12th Street SW, Washington, DC 20024-2188, Privacy Statement However, code 96127 should be reported for both screening and follow-up of. No modifier is necessary because the commercial payer does not bundle 96110 with 99392 and allows two units per date of service as the maximum allowable for code 96110. This is based on CPT guidance for central nervous system assessments that states, It is expected that the administration of these tests will generate material that will be formulated into a report. Verify your payers' documentation requirements prior to providing these services. If your session expires, you will lose all items in your basket and any active searches. CPT code 96160 allows allergists to get reimbursed when they make use of certain standardized asthma assessment instruments. In addition, most are recommended preventive services, and some may also be factored into performance ratings and quality initiatives. The list of results will include documents which contain the code you entered. Codes 96110, 96160, and 96161 are typically limited to developmental screening and the health risk assessment (HRA). Do You Have What It Takes to Be a Mental Health Coding Maven? This First Coast Billing and Coding Article for Local Coverage Determination (LCD) L33834 Health and Behavior Assessment/Intervention provides billing and coding guidance for frequency limitations as well as diagnosis limitations that support diagnosis to procedure code automated denials. No fee schedules, basic unit, relative values or related listings are included in CPT. Report code 96161 for a health risk assessment when focused on care-giver risk that may impact the patient's health (e.g., postpartum depression). There have been no updates to the code since its addition. See the CMS . DOCUMENTATION GUIDELINES 96110 Each administered developmental screening instrument is accompanied by scoring and documentation (eg, a score or designation as normal or abnormal). CPT codes 96150 - 96154 are to be billed as one service for each 15 minute of face-to-face contact with the beneficiary(s). What Counts as a Standardized Instrument? Your MCD session is currently set to expire in 5 minutes due to inactivity. If you are looking for a specific code, use your browser's Find function (Ctrl-F) to quickly locate the code in the article. Instructions for enabling "JavaScript" can be found here. Was your Medicare claim denied? Depression screening, reported with 96127, is typically a covered preventive service for adolescents age 12 to 18 and is a quality measure in many pediatric quality initiatives. G0439 - Subsequent visit. Reproduced with permission. Separate billing for scoring and report preparation is not allowed. All Rights Reserved. Because most payment policies are regional rather than national and accessible only through secure provider portals, providing a comprehensive list is beyond the scope of this article. recommending their use. End Users do not act for or on behalf of the CMS. Washington Apple Health means the public health insurance programs for eligible Washington residents. Code 96160 is for the patient, who may have risks that impact their health but that have not yet been diagnosed, says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington. The guidelines of the Correct Coding Initiative (CCI) supersede all coding instructions in this Billing and Coding Article. Please try reloading page. If you are acting on behalf of an organization, you represent that you are authorized to act on behalf of such organization and that your acceptance of the terms of this agreement creates a legally enforceable obligation of the organization. The views and/or positions

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