Know What HRA Services Are Included in Preventive Medicine Counseling
New preventive medicine mandates call for healthy coding habits of these services.
By Shelly Cronin, CPC, CPMA, CANPC, CGSC, CGIC
With the Centers for Medicare & Medicaid Services’ (CMS’) renewed focus on preventive medicine visits, there’s been some confusion about what is included in preventive medicine counseling and health and behavior assessments, who can bill for them, and when.
The Patient Protection and Affordable Care Act of 2010 specifies that a health risk assessment (HRA) must be included as part of the preventive medicine counseling visit. This assessment includes all activities known only to an individual patient, such as smoking, physical activity, and nutritional habits. The purpose of this assessment is to allow the provider to give feedback tailored to the information collected (prior to or during the visit) to promote health, and to reduce illness and injury (see www.healthcare.gov/center/authorities/title_iv_prevention_of_chronic_disease.pdf).
HRA Scenarios Provide Proper Coding
Preventive medicine counseling and risk factor reduction interventions vary with age, and should address such issues as family problems, diet and exercise, substance use, sexual practices, injury prevention, dental health, and diagnostic and laboratory test results available at the time of the encounter. For instance, consider the following HRA examples:
A patient and his family arrive at their family practice office to see the physician for counseling and instructions regarding the patient’s desire to start a healthy eating plan. The physician meets with the patient and his family to discuss the benefits of a healthy diet, and to discuss some of the physical changes that will accompany the diet, such as weight loss, increased energy, improved mood, and so on. The physician then recommends that the family meet with a registered dietician to outline a meal plan, and discusses how to incorporate this lifestyle into their day-to-day life. Start time: 9:30 a.m. Stop time: 10 a.m.
Correct coding is CPT® 99402; ICD-9 V65.49 Other specified counseling.
A patient is seen in his primary care physician’s office to discuss smoking cessation. The patient briefly speaks to Dr. Smith regarding options for quitting his smoking habit. Dr. Smith informs him of the various medications and recommends the patient review additional information on the Internet. The patient agrees. Start time: 1:15 p.m. Stop time: 1:25 p.m.
Correct coding is CPT® 99406; ICD-9 V65.42 Counseling on substance use and abuse.
Behavior Change Intervention Guidance
Behavior change interventions are for persons who have a behavior often considered an illness itself (such as tobacco use and addiction, substance abuse/misuse, or obesity). Behavior change services may be reported when performed as part of the treatment of condition(s) related to, or potentially exacerbated by, the behavior; or, when performed to change the harmful behavior that has not yet resulted in illness.
Behavior change services involve specific validated interventions of assessing readiness for change and barriers to change, advising a change in behavior, assisting by providing specific suggested actions and motivational counseling, and arranging for services and follow-up. Any E/M services reported on the same day must be distinct, and time spent providing these services may not be used as a basis for the E/M code selection.
Codes 96150-96155 capture a wide range of physical health issues—from patient compliance to medical treatment, symptom management, health-promoting behaviors, health-related risk-taking behaviors, and overall adjustment to physical illness. In most cases, a physician will already have diagnosed the patient’s physical health problem.
Behavioral Change Invention
Examples Show Correct Code Choices
The patient is a 56-year-old female recently diagnosed with stage IV breast cancer. She is undergoing both aggressive chemotherapy and radiation treatments. She arrives at her provider’s office with her family for an initial health and behavioral assessment evaluation. The patient is seen initially to address issues of pain management via imagery, breathing exercises, and other therapeutic interventions; and to discuss quality of life issues, treatment options, and death and dying issues.
Due to the medical protocol and the patient’s inability to travel to additional sessions between hospitalizations, a plan is developed for extending treatment at home with the patient’s husband and sister as co-caregivers. The patient’s family is seen by the health care provider for training in how to assist the patient in objectively monitoring her pain and in applying exercises learned via her treatment sessions to manage pain. Issues of the patient’s quality of life—as well as death and dying concerns—are also addressed with assistance given to the husband and sister as to how to make appropriate home interventions between sessions. Effective communication techniques with his wife’s physician and other members of his medical team regarding her treatment protocols are facilitated. Start time: 2 p.m. Stop time: 3 p.m.
Correct coding is CPT® 96154 x 4; ICD-9 174.9 Malignant neoplasm of female breast, unspecified.
The patient is a 21-year-old male who is recently diagnosed as an insulin-dependent diabetic. The patient reports anxiety and pain with injections and blood glucose testing. An individual-based approach is used to address the patient’s anxiety problems. Relaxation and distraction techniques are used to address the patient’s anxiety with finger sticks and injections. The patient practices these techniques in the office with success and feels comfortable about reproducing these results on his own. Start time: 8 a.m. Stop time: 8:45 a.m.
Correct coding is CPT® 96152 x 3; ICD-9 250.00 Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled, V58.67 Long-term (current) use of insulin.
Use Caution When Combining Services
For a provider treating a patient with both a physical and mental illness, reporting each service requires careful attention. This is because health and behavior codes cannot be used for psychotherapy services (addressing the patient’s mental health diagnosis), nor can they be reported on the same day as psychiatric or E/M CPT® codes. For patients that require psychiatric services (90801-90899), as well as health and behavior assessment/intervention (96150-96155), report the predominant service performed. Per CPT®, health and behavior assessment/intervention services (96150-96155) should not be reported on the same day as HRA (99401-99412).
Example: The patient is a 15-year-old male who was recently diagnosed with chronic asthma and who has an existing diagnosis of bipolar I. He arrives with his family for an assessment of the patient’s emotional, social, and medical treatment related to the chronic asthma, hospitalizations, and treatments. Test results from the assessment provide information for treatment planning that includes health and behavior interventions involving a combination of behavioral cognitive therapy, relaxation response training, and visualization. The patient’s mother then discusses that the patient has been experiencing more manic type episodes, which was confirmed by the patient. The patient is currently on lithium, which has been able to reduce the frequency of the patient’s bipolar episodes. I then spend 30 minutes discussing the various medication options, benefits, and drawbacks of each medication with the patient and his mother, who agrees to try a higher dosage of lithium for now because it has worked in the past. The prescription is given to the patient’s mother with the instruction to follow up with me in three weeks.
Diagnosis: Bipolar I, with mild manic episode. Please note that I spent a total of 15 minutes performing the assessment and 30 minutes discussing options of medication changes with the patient and his mother. Start Time: 10 a.m. Stop time: 10:45 a.m.
Correct coding is 90807 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services and 296.41 Bipolar I disorder, most recent episode (or current) manic, mild.
According to the guidelines, it’s appropriate to report psychotherapy CPT® code 90807 rather than 96154 because the provider spent the majority of the appointment time discussing and providing treatment for the patient’s bipolar disorder, as documented in the note.
Coordination of Care is Required
CMS carriers are looking for documentation that shows coordination of care with the patient’s primary care provider, or the medical provider who is in management of the patient’s illness being addressed by the psychological assessment/intervention. For example, Cahaba Government Benefit Administrators®, LLC, requires documentation of:
- Evidence of a referral to the clinical psychologist for the initial assessment and for each reassessment
- Evidence of coordination of care with the beneficiary’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
- The ICD-9-CM code that reflects the condition of the beneficiary and clearly indicates the reason for the service
Initial assessment (96150) documentation in the medical record by the clinical psychologist must include documentation 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
- Clear rationale for why assessment is required
- Assessment outcome including mental status and ability to understand and to respond meaningfully
- Goals and expected duration of specific psychological intervention(s), if recommended
Reassessment (96151) documentation must include the following elements:
- Date of change in mental or physical status
- Clear rationale for why reassessment is required
- Clear indication of the precipitating event that necessitates reassessment
Intervention service (96152-96154) documentation supporting that the intervention is reasonable and necessary must include, at a minimum, the following elements:
- Evidence that the beneficiary has the capacity to understand and to respond meaningfully
- Clearly defined psychological intervention plan and goals
- Goals of the psychological intervention clearly stating how the service is expected to improve compliance with the medical treatment plan
- The response to the intervention indicated
- Rationale for frequency and duration of services
- Time duration (stated in minutes) for each visit spent in the health and behavioral assessment or intervention encounter
Per CMS, you are not required to submit medical records with the claim; however, the medical record (e.g., complete nursing home record, doctor’s orders, progress notes, office records, and nursing notes) must be complete and available to the carrier upon request.
Telehealth Services Require Modifiers
In 2010, CMS included 96150-96152 and G0425-G0427 into their distant site telehealth services for individual health and behavior assessment and intervention (HBAI) services. Effective Jan. 1, 2010 these codes are valid when billed for services furnished to beneficiaries in hospitals or skilled nursing facilities (SNFs), and properly reported with the corresponding interactive telehealth modifiers GT Via interactive audio and video telecommunication systems and GQ Via asynchronous telecommunications system. These changes allow the providers to retain the ability for providers to furnish and bill for consultations performed via telehealth.
As always, the best practice is to check with your region’s specific payer policies prior to reporting any of these services to verify that they are covered and learn of any qualifying factors that may apply.
HRA CPT® Codes
99401 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes
99402 approximately 30 minutes
99403 approximately 45 minutes
99404 approximately 60 minutes
99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes
99407 intensive, greater than 10 minutes
99408 Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes
99409 greater than 30 minutes
99411 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure); approximately 30 minutes
99412 approximately 60 minutes
These services are distinct from evaluation and management (E/M) services, and may be reported separately when performed face-to-face by providers or other qualified health care professionals as a separate encounter.
Behavior Change Interventions CPT® Codes
96150 Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment
96152 Health and behavior intervention, each 15 minutes, face-to-face; individual
96153 group (2 or more patients)
96154 family (with the patient present)
96155 family (without the patient present)
These codes are for mental health providers to report services provided to patients with primary physical illnesses/diagnoses/symptoms. These services are offered to patients who may benefit from assessments and/or interventions focused solely on biopsychosocial factors related to the health status of the patient. Behavioral health providers use these assessments to indentify certain factors important to the care and treatment of physical health problems associated with a patient’s behavioral, cognitive, emotional, psychological, and social status. When these codes where developed almost all intervention codes used by psychologists involved psychotherapy and required a mental health diagnosis. Health/behavior assessment and intervention services focus on patients whose primary diagnosis is physical in nature.
Preventive medicine counseling and risk factor reduction interventions vary with age and should address such issues as family problems, diet and exercise, substance use, sexual practices, injury prevention, dental health, and diagnostic and laboratory test results …
… health and behavior codes cannot be used for psychotherapy services (addressing the patient’s mental health diagnosis), nor can they be reported on the same day as a psychiatric or E/M CPT® codes.
Shelly Cronin, CPC, CPMA, CANPC, CGSC, CGIC, is AAPC’s CEU vendor department manager.