Pediatric Coding Alert

Question: We are not able to get any payers to cover 3085F when billed with an office visit. Why is that?

AAPC Forum Participant

Answer: Some payers may have 3085F (Suicide risk assessed (MDD, MDD ADOL)) listed on their fee schedules, but Medicare and most commercial payers do not. That’s because 3085F is a Category II CPT^® code. Category II codes are optional, unless required by your payer contracts, and intended for measuring performance on quality metrics, not for reimbursement.

Or, as the American Medical Association (AMA) says that CPT^® Category II codes, they are “supplemental tracking codes that can be used for performance measurement. The use of the tracking codes for performance measurement will decrease the need for record abstraction and chart review, and thereby minimize administrative burdens on physicians and other health care professionals” (www.ama-assn.org/practice-management/cpt/criteria-cpt-category-ii-codes).

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If your provider assessed the patient using tests such as Home, Education, Eating, Activities, Drugs and Alcohol, Suicide and Depression, Sexuality and Safety (HEEADSSS), then reimbursement is an option with code 96160 (Administration of patient-focused health risk assessment instrument [eg, health hazard appraisal] with scoring and documentation, per standardized instrument) — a health risk assessment (HRA) code — to assess how a psychological condition is affecting a patient’s physical condition. You’ll report that code when the provider assesses how a mental health condition is affecting, or can potentially affect, a patient’s physical health.

As always, if the notes are unclear regarding what occurred during any office visit, query your provider for additional details.