documentation requirements for cpt code 96160

Child Development/Developmental Monitoring and Screening. Further Clarifications on the Use of 96160 and 96161 For example, Texas Health Steps pays for adolescent mental health screening using specified structured instruments reported with code 96160 when completed by the patient, and 96161 when completed by a caregiver. It is appropriate to bill the 96160 CPT code when a healthcare provider administers a standardized patient-focused health risk assessment instrument, scores the results, and documents the findings in the patients medical record. (e.g., transition readiness assessment) with scoring and documentation, per standardized instrument $2.77 NA 0.08 . MLN6775421 - Medicare Wellness Visits - Centers for Medicare Medical records need not be submitted with the claim; however, the medical record, (e.g., nursing home record, doctors orders, progress notes, office records, and nursing notes), must be available upon request. An official website of the United States government. The Medicare program provides limited benefits for outpatient prescription drugs. Be sure that your billing staff is aware of National Correct Coding Initiative and other payer edits that may bundle or limit the units of service for screening and assessment codes. Enter the code you're looking for in the "Enter keyword, code, or document ID" box. By clicking below on the button labeled "I accept", you hereby acknowledge that you have read, understood and agreed to all terms and conditions set forth in this agreement. If the physician is providing the global obstetrical service (and reporting a global code), the payer may consider screening depression as part of the global service and not reimburse additionally for the service. For more information, please visit ACOGs Solutions section (May 2015, Perinatal Depression). For purpose of this exclusion, "the term 'usually' means more than 50 percent of the time for all Medicare beneficiaries who use the drug. Because health risk assessments (HRAs) appear so similar to other assessment services, using the HRA codes can be a real gamble. s an evaluation of psychological, behavioral, emotional, cognitive and social factors that affect the patients response. 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. Please contact your Medicare Administrative Contractor (MAC). If your session expires, you will lose all items in your basket and any active searches. Coding Question: Postpartum Depression Screening | ACOG The CPT Codes discussed in this Billing and Coding Article are used to report the services provided during testing of the cognitive function of the central nervous system. 25 PDF Developmental Screening/Testing Coding Fact Sheet for Primary - CDC Procedure Codes for Screening and Assessment Services accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the You will find them in the Billing & Coding Articles. Please note that if you choose to continue without enabling "JavaScript" certain functionalities on this website may not be available. The program covers drugs that are furnished "incident-to" a physician's service provided that the drugs are not "usually self-administered" by the patient. Developmental surveillance without use of a structured screening instrument is included in the preventive medicine service and not separately reported. CPT 96150: This code is used for an initial health and behavior assessment conducted by a healthcare professional. CPT 96160 was added to the Current Procedural Terminology system on January 1, 2017. Collaboration between practice managers, coding and billing staff, and physicians is needed to provide and be appropriately paid for these services. Example B: Imagine the same scenario as in example A, but the patient has a different health plan. 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. contact your MAC for guidance. For example, the assessment might be done on a new mother to see if there is any problem, such as postpartum depression, that could affect the care of the patient, Bucknam adds. Documentation in the medical record by the Clinical Psychologist (CP) must include: For the initial assessment, progress notes must include at a minimum the following elements: Onset and history of initial diagnosis of physical illness, and, Clear rationale for why assessment is required, and, Assessment outcome including mental status and ability to understand or respond meaningfully, and. Do not report preparation and scoring separately. PDF CMS Manual System The CPT guidelines for 96156-96161 provide an important reminder about how 96160/96161 differ from two other screening and assessment codes: 96110 (Developmental screening [eg, developmental milestone survey, speech and language delay screen] with scoring and documentation, per standardized instrument) and 96127 (Brief emotional/behavioral assessment with scoring and documentation, per standardized instrument). Please visit the. apply equally to all claims. Because health risk assessments (HRAs) appear [], Check Your Answers to Our Mental Health Coding Quiz, Time to find out if youre a Chapter 5 ace. Use for developmental and autism screening. All Rights Reserved. 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. Any questions pertaining to the license or use of the CPT should be addressed to the AMA. Documentation Requirements All documentation must be maintained in the patient's medical record and made available to the contractor upon request. Recent changes to CPT codes for structured screenings and brief assessments have led some payers to expand coverage for these services. Applicable FARS/HHSARS apply. Heres your chance to prove you know your way around the F01-F99 codes. HCPCS/CPT Codes. 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. This is particularly true if the physician routinely screens every patient for depression. All comments are moderated and will be removed if they violate ourTerms of Use. When billing for non-covered services, use the appropriate modifier. Try entering any of this type of information provided in your denial letter. A healthcare provider administers a skin cancer risk assessment questionnaire to a patient with a history of sunburns and tanning bed use. The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Cognitive Assessment and Care Plan Service L39266. That portion of the visit must be medically necessary and reasonable to treat the patient's illness or injury or to improve the functioning of a malformed body part. 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. article does not apply to that Bill Type. In this article, we will review the documentation and billing requirements necessary for getting paid. 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. An asterisk (*) indicates a if(typeof ez_ad_units != 'undefined'){ez_ad_units.push([[320,100],'codingahead_com-box-3','ezslot_1',147,'0','0'])};__ez_fad_position('div-gpt-ad-codingahead_com-box-3-0');CPT 96160 is a medical billing code used to represent the administration of a patient-focused health risk assessment instrument, such as a health hazard appraisal, with scoring and documentation. ICD-10 codes for routine health examinations (Z00.0-, Z00.1-) should be reported in conjunction with recommended HRAs performed at the same encounter. Changes to CPT codes for structured screenings and brief assessments have led some payers to expand coverage for these services. However, services performed for any given diagnosis must meet all of the indications and limitations stated in the LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules. The patient is reluctant to take any medication due to her addiction. Required fields are marked *. CPT 96146: This code is used for the administration of a computerized adaptive psychological or neuropsychological test with a qualified health professionals interpretation and report. Billing and Coding: Cognitive Assessment and Care Plan Service All rights reserved. Do You Have What It Takes to Be a Mental Health Coding Maven? Washington Apple Health means the public health insurance programs for eligible Washington residents. If you need an accommodation or require documents in another format, please call 1-800-562- 3022. To see a description of each code and examples of standardized instruments that may be used for each, see Quick reference: Screening and assessment codes. CPT Assistant has described a standardized instrument as a previously validated test that is administered and scored in a consistent or standard manner. Validated structured instruments have been shown through study to provide consistent and reliable results. Health and behavioral assessment is an evaluation of psychological, behavioral, emotional, cognitive and social factors that affect the patients response. Example: An 18-month-old established patient is seen for a well-child exam. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. The patient completes the questionnaire, providing information about their health and lifestyle. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. 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. CRs are not policy, rather CRs are used to relay instructions regarding the edits of the various claims processing systems in very descriptive, technical language usually employing the codes or code combinations likely to be encountered with claims subject to the policy in question. Compliance with the provisions in LCD L33834, Health and Behavior Assessment/Intervention may be monitored and addressed through post payment data analysis and subsequent medical review audits. However, only 96160/96161 involve administering, scoring, and documenting a standardized instrument. All Rights Reserved. (96160/96161) Codes 99408/99409 cannot be reported for the same patient, on the same date of service, as Health Behavior Assessment . Contractors may specify Bill Types to help providers identify those Bill Types typically Draft articles are articles written in support of a Proposed LCD. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The CMS.gov Web site currently does not fully support browsers with CPT 96161: This code is used for the administration of a caregiver-focused health risk assessment instrument, such as a depression inventory, for the benefit of the patient. Four codes are used to report structured screening and assessments: 96110, Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument,, 96127, Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder scale), with scoring and documentation, per standardized instrument,, 96160, Administration of patient-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation, per standardized instrument,, 96161, Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument.. HCPCS modifiers such as modifier EP may be required by Medicaid plans to indicate a service was provided as part of a Medicaid early periodic screening diagnosis and treatment program, or they may require other state-defined modifiers. or call toll-free from U.S.: (800) 762-2264 or (240) 547-2156 CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. A patient with a history of alcohol abuse completes a liver disease risk assessment instrument. Refer to the current HCPG for examples of other scientifically validated screening tools for adolescent health risk. A healthcare provider administers a cardiovascular risk assessment questionnaire to a patient with a family history of heart disease. Most payers allow two units (i.e., instruments) per date of service for code 96110. Response to Comment (RTC) articles list issues raised by external stakeholders during the Proposed LCD comment period. 27) Encounter for routine child health exam with abnormal findings Depression Screening (pg. End User Point and Click Amendment: Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service [s]). Copyright 2017 by the American Academy of Family Physicians. Simply put, the two differ over who is being assessed. "CPT Copyright American Medical Association. The physician's interpretation of the score in light of the patient presentation is considered part of the evaluation and management (E/M) service, which would be billed in addition to the screening or assessment code. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be ICD-10 webpage for individual CRs and coding translations for ICD-10 and . The effective date of this . The scope of this license is determined by the AMA, the copyright holder. Codes 96160-96161 are reported in addition to the evaluation and management (E/M) code (eg, 99213). Quality initiatives that include incentives for performing and reporting recommended screenings and assessments are an additional reason to familiarize yourself with these four codes: 96110, Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument,, 96127, Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder scale), with scoring and documentation, per standardized instrument,, 96160, Administration of patient-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation, per standardized instrument,, 96161, Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument.. Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Applicable FARS\DFARS Restrictions Apply to Government Use. 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. 4) Visit Medicare.gov or call 1-800-Medicare. CPT code 96160 allows allergists to get reimbursed when they make use of certain standardized asthma assessment instruments. The effective date of this revision is based on date of service. The list of results will include documents which contain the code you entered. Federal government websites often end in .gov or .mil. Was your Medicare claim denied? Unless specified in the article, services reported under other (For more information, see Screening Your Adult Patients for Depression, FPM, March/April 2016.) In most cases, modifiers will override the edits when clinically appropriate. 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. Sign up to get the latest information about your choice of CMS topics in your inbox. All rights reserved. Code 96127 is also applicable to assessments for conditions such as anxiety, attention-deficit disorders, and generalized psychosocial symptoms (e.g., pediatric symptom checklist). You must know your specific payer policies. Developmental screening reported with code 96110 is paid for by 45 state Medicaid programs with rates varying from approximately $5 to $60.1 Many private insurers also provide preventive benefits for code 96110 for developmental screening at nine months, 18 months, and 30 months, and autism screening at 18 months and 24 months in addition to the recommended preventive medicine E/M services (e.g., well-child visits). Please do not use this feature to contact CMS. End User License Agreement: When using Edinburgh Postnatal Depression Screening to screen for depression in pregnant or postpartum patients, it is more appropriate to report CPT code 96160, Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument. CMS and its products and services are not endorsed by the AHA or any of its affiliates. The instrument is standardized. 21) 6. The following CPT codes associated with the services outlined in this Billing and Coding Article will not have diagnosis code limitations applied at this time. The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. CPT is a trademark of the American Medical Association (AMA). Screening and assessment services should be reported unless a payer's written policy restricts doing so. Documentation Requirements. copied without the express written consent of the AHA. Article revised and published on 9/9/2021 effective for dates of service on and after 01/01/2020 in response to an inquiry for clarification to the article. Bulk pricing was not found for item. For instance, Aetna has a long-standing policy to cover depression screening in primary care when the service is performed using the Patient Health Questionnaire-9 (PHQ-9) tool and is reported with code 96127. For the most part, codes are no longer included in the LCD (policy). When reporting CPT codes 96159, 96165, and 96168, the quantity billed should reflect 1 unit for each 15 minutes. This content is owned by the AAFP. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). not endorsed by the AHA or any of its affiliates. The following CPT codes are not applicable for developmental delay screening or testing: 96160, 96161, 99411, 99412, 99429. What Counts as a Standardized Instrument? that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes. End Users do not act for or on behalf of the CMS. If you dont find the Article you are looking for, contact your MAC. 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. If a redetermination is requested, documentation showing the Documentation 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/scoring the instrument. CPT codes 96158, 96164, and 96167 should not be reported for less than 16 minutes of service. Refer to the LCD for reasonable and necessary requirements and limitations. However, code 96127 should be reported for both screening and follow-up of. When more than four CPT codes 96150 are submitted by a provider/group the additional services will be denied. 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. The document is broken into multiple sections. Goals and expected duration of specific psychological intervention(s), if recommended. 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. Do your [], Heres your guide to risk-free screening and assessment coding. The HRA codes are subject to PTP edits when reported with the other screening and assessment codes, however. Simply put, the two differ over who is being assessed. GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION, PRODUCT, OR PROCESSES 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). Staff administer and score two structured screening instruments for development and autism. Instructions for enabling "JavaScript" can be found here. However, if the physician diagnoses depression, you may report it separately since the global package was valued for uncomplicated antepartum, delivery, and postpartum care. 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. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. 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. Code 99483 provides reimbursement to physicians and other eligible billing practitioners for a comprehensive clinical visit that results in a written care plan . Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not PDF Coding for Standardized Assessment, Screening and Testing This Agreement will terminate upon notice if you violate its terms. 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. How Do 96160/96161 Differ From Each Other? Also, you can decide how often you want to get updates. 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.

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