by Jim Georgoulakis, Ph.D.
Calendar year 2002 represents a landmark year in terms of the contributions and recognition of the success of cognitive, behavioral, social, and psychophysiological procedures in the amelioration of specific disease-related problems. This recognition is due to the combination of successful clinical outcome studies and inclusion in the American Medical Associationís (AMA) Current Procedural Terminology (CPT) System and the acceptance by the Center for Medicaid and Medicare Services (CMS) formerly the Health Care Financing Administration (HCFA). CPT developed specific definitions and guidelines for the codes and the application of the codes to clinical practice. The AMAís Resource Value Update Committee (RUC) developed and assigned work, practice expense and malpractice expense values to each of the individual codes. The resulting code values are utilized by CMS and other payors to assign reimbursement rates for the codes.
The Health and Behavior Assessment Intervention Codes are assigned to the Medicine section of the CPT code book and are not considered mental health intervention services. This is significant for mental health practitioners for a number of reasons. First, it represents clear recognition of the value of cognitive, behavioral, social and psychophysiological procedures beyond the traditional mental health realm. Second, the assignment of a work value for the services indicates that these are procedures that should only be performed by physicians, psychologists, or other qualified health care professionals. Third, from a federal reimbursement perspective, monies to pay for these services will be paid out of the medicine pool rather than the psychiatric pool. Thus the provision of these services will not require the expenditures of limited mental health dollars. Fourth, the application of these codes are expected to be for individuals not meeting the criteria for a psychiatric diagnosis, thus allowing patients without mental health problems access to these services. Fifth, the development and application of the codes allow for the treatment of the biopsychosocial factors important to physical health problems and treatments that in many cases will greatly facilitate improved health for the patient.
At the present time (Calendar year 2002) six (6) CPT codes have been developed for health and behavior assessment services. These codes represent services that can be offered to patients who present with established illnesses or symptoms, who are not diagnosed with a mental illness (see Diagnostic and Statistical Manual of the American Psychiatric Association Fourth Edition-DSM-IV and the International Classification of Diseases Ninth Edition with Clinical Modification-ICD-9-CM), and may benefit from evaluations and treatments that focus on the biopsychosocial factors related to the patientís physical health status such as patient adherence to medical treatment, symptom management and expression, health-promoting behaviors, health-related risk-taking behaviors, and overall adjustment to mental illness. Previously, no codes were available to provide treatment for these conditions.
The intervention codes are used
to describe procedures that modify the psychological, behavioral, cognitive,
and social factors identified as important to or directly affecting the
patientís physiological functioning, disease status, health and well being.
The focus of the intervention is to improve the patientís health and
well-being via cognitive, behavioral, social and/or psychophysiological
procedures designed to ameliorate specific disease related problems.
The first code in the family of health and behavior assessment/intervention codes is numbered 96150 for calendar year 2002 in both the American Medical Associationís (AMA) Current Procedural Terminology (CPT) and the Center for Medicaid and Medicare Servicesí (CMS) Health Care Common Procedural Coding System (HCPCS). The description of the code is as follows: A 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 ( CPT 2002).
A clinical description of the code is as follows: A 5-year-old boy undergoing treatment for acute lymphoblastic leukemia is referred for assessment of pain, severe behavioral distress and combativeness associated with repeated lumbar punctures and intrathecal chemotherapy administration. Previously unsuccessful approaches have included pharmacologic treatment of anxiety (Ativan), conscious sedation using Versed and finally, chlorohydrate, which only exacerbated the childís distress as a result of partial sedation. General anesthesia was ruled out because the childís asthma increased anesthesia respiratory risk to unacceptable levels.
The patient was assessed using standardized questionnaires (e.g., the Information-Seeking Scale, Pediatric Pain Questionnaire, Coping Strategies Inventory) which, in view of the childís age, were administered in a structured format. The medical staff and childís parents were also interviewed. On the day of a scheduled medical procedure, the child completed a self-report distress questionnaire. Behavioral observations were also made during the procedure using the CAMPIS-R, a structured observation scale that quantifies child, parent, and medical staff behavior.
This case example clearly indicates the focus was not the assessment of a mental health condition but on biopsychosocial factors affecting the physical health and treatment problems of the child. The case has been designed to represent the typical patient.
The service should be billed in increments (units) of 15 minutes. The typical amount of time for this service is considered to be 90 minutes.
The description of code 96151 Health and Behavior Re-assessment represents a re-assessment of a previously assessed patient. This re-assessment may or may not be conducted by the clinician who conducted the initial assessment of the patient.
A clinical example includes the following: A 35-year-old female diagnosed with chronic asthma, hypertension, and panic attacks was originally seen 10 months ago for assessment and follow-up treatment. Original assessment included an extensive interview regarding the patientís emotional, social and medical history, including her ability to manage problems related to the chronic asthma, hospitalizations and treatments. Test results from original assessment provided information for treatment planning which included health and behavior interventions involving a combination of behavioral cognitive therapy, relaxation response training and visualization. After four months of treatment interventions, the patientís hypertension and anxiety were significantly reduced, and the patient was discharged. Now six months following discharge the patient has injured her knee and has undergone arthroscopic surgery with follow-up physical therapy.
The patient was seen to reassess and evaluate psychophysiological responses to these new health stressors. A review of the records from the initial assessment, testing, and treatment intervention, as well as current medical records was made. Patientís affective and psychological status, compliance disposition, and perceptions of efficacy of relaxation and visualization practices utilized during previous treatment intervention are examined. Administration of anxiety inventory/questionnaire (e.g., Burns Anxiety Inventory) is used to quantify the patientís current level of response to present health stressors and compared to original assessment levels. The need for further treatment is evaluated. A re-assessment of the patientís condition was performed through the use of interview and behavioral health instruments.
The above example has been designed to illustrate to the psychologist the use of the code. It is important to note that the case example represents the typical patient. This service should be billed in increments of 15 minutes.
Behavior Intervention - Code Number 96152
Health and Behavior Intervention - Code Number 96152
The description of code 96152 is simply health and behavior intervention, each l5 minutes, face-to-face; individual. A clinical example would include a 55-year-old executive with a history of cardiac arrest, high blood pressure and cholesterol, and a family history of cardiac problems. He is 30 pounds overweight, travels extensively for work, and reports to be a moderate social drinker. He currently smokes approximately one-half pack of cigarettes a day, although he has periodically attempted to quit smoking for up to 5 weeks at a time. The patient is considered by his physician to be a type A personality and at high risk for cardiac complications. He experiences angina pains one or two times per month. The patient is seen by a behavioral medicine specialist. Results from the health and behavioral assessment are used to develop a treatment plan, taking into account the patientís coping skills and lifestyle.
The treatment for this patient may include weekly intervention sessions focusing on psychoeducational factors impacting on his awareness and knowledge about his disease process, and the use of relaxation and guided imagery techniques that directly impact his blood pressure and heart rate. Cognitive and behavioral approaches for cessation of smoking and initiation of an appropriate physician-prescribed diet and exercise regimen are also employed.
This example clearly demonstrates that the treatment focus of the psychologist is on the biopsychosocial factors impacting on the patientís condition. Additionally, this example illustrates the integration of cognitive and behavioral approaches to alleviate the condition .
The health and behavior intervention, each 15 minutes, group (2 or more patients) has been developed to provide intervention services in a group setting. The typical group size for this service is considered to be 8 to 10 patients and the typical time is 90 minutes. Examples of this service include educational information (e.g., health risks, nicotine addiction), cognitive-behavioral treatment (e.g., self-monitoring, relaxation training, and behavioral substitution), and social support (e.g., group discussion, social skills training).
A typical clinical example would be: A 45-year-old female is referred for smoking cessation secondary to chronic bronchitis, with a strong family history of emphysema. She smokes two packs per day. The health and behavior assessment indicates that the patient uses smoking as a primary way of coping with stress. Social influences contributing to her continued smoking include several friends and family members who also smoke. The patient has made multiple previous attempts to quit on her own. When treatment options are reviewed, she is receptive to the recommendation of an eight-week group cessation program.
This example illustrates the
application of health and behavior intervention techniques as required for the
appropriate utilization of the code.
The health and behavior intervention, each 15 minutes, face-to-face, with family and with the patient present is designed to address the multiple components of the patientís behavioral problems. A typical clinical example could be a 9-year-old girl diagnosed with insulin-dependent diabetes two years ago. Her mother reports great difficulty with morning and evening insulin injections and blood glucose testing. The patient whines and cries, delaying the procedures for 30 minutes or more. She refuses to give her own injections or conduct her own glucose tests, claiming they hurt. Her mother spends many minutes pleading for her cooperation. The patientís father refuses to participate, saying he is afraid of needles. Both parents have not been able to go to a movie or dinner alone, because they know of no one who can care for the child. The patientís 10-year-old sister claims she never has any time with her mother, since their mother is always preoccupied with her sisterís illness. The patient and her sister have a poor relationship and are always quarreling. The patientís parents frequently argue; her mother complains that she gets no help from her husband, and the father complains that his wife has no time for anyone else.
A typical treatment plan may include relaxation and exposure techniques used to address the fatherís fear of injections, which he has been inadvertently modeling for his daughter. The patient may be taught relaxation and distraction techniques to reduce the tension she experiences with finger sticks and injections. Both parents are taught to shape the childís behavior, praising and rewarding successful diabetes management behaviors, and ignoring delay tactics. Her parents are also taught judicious use of time-out and response cost procedures. Family roles and responsibilities are clarified. Clear communication, conflict resolution, and problem solving skills are taught. Family members practice applying these skills to a variety of problems so that they will know how to successfully address new problems that may arise in the future.
It is important to note that
different clinicians may develop different treatment approaches.
This is not only acceptable but expected. However,
the treatment plan that is implemented must include clinically accepted health
and behavior intervention procedures.
The final code in the family of health and behavior intervention includes family intervention services without the patient present. This service is billed in increments of 15 minutes.
A typical clinical example is a 42-year-old male diagnosed with cancer of the pancreas. He is currently undergoing both aggressive chemotherapy and radiation treatments. However, his prognosis is guarded. At present, he is not in the endstage disease process and therefore does not qualify for hospice care. The patient is seen initially to address issues of pain management via imagery, breathing exercises, and other therapeutic interventions to address quality of life issues, treatment options, and death and dying issues.
A possible treatment plan scenario may include the following: due to the medical protocol and the patientís inability to travel to additional sessions between hospitalizations, a plan is developed for extending treatment at home via the patientís wife, who is his primary home caregiver. The patientís wife is seen by the healthcare provider to train the wife in how to assist the patient in objectively monitoring his pain and in applying exercises learned via his treatment sessions to manage pain. Issues of the patientís quality of life, as well as death and dying concerns are also addressed with assistance given to the wife as to how to make appropriate home interventions between sessions. Effective communication techniques with her husbandís physician and other members of his treatment team regarding the treatment protocols are facilitated.
The above scenario illustrates the proper utilization of the code for the clinical vignette accompanied with an appropriate treatment plan.
The establishment of health and
behavior assessment codes clearly represents progress in the treatment of
physical disorders and diseases. However,
it is imperative that psychologists understand the codes will be subject to
the guidelines included in the National Correct Coding Initiative (NCCI).
The NCCI is utilized by a number of payors including Medicare.
Essentially, the NCCI represents guidelines for the use of CPT/HCPCS
codes. More specifically some of the NCCI guidelines that apply to the health
and behavior assessment codes include the following:
1. The codes cannot be utilized with patients that have a disease meeting the criteria for a psychiatric diagnoses.
2. For patients that require psychiatric services as well as health and behavior assessment interventions, the clinician must report the predominant service performed.
Clinicians cannot report the psychiatric codes on the same day as the
health and behavior assessment codes.
It is imperative that
psychologists become familiar with not only the use of the codes but the rules
addressing the utilization of the codes. For additional information contact
Dr. Jim Georgoulakis at (210) 820-3966 or firstname.lastname@example.org or Dr. Tony
Puente at (910) 962-3812.