Psychologists will soon have a more accurate, refined way of billing for services provided to patients with a physical health diagnosis, thanks to the advent of six new CPT codes. Effective this month, codes for health and behavior assessment and intervention services will apply to behavioral, social, and psychophysiological procedures for the prevention, treatment or management of physical health problems. New codes to be paid with physical health dollars.

Use of the new codes will enable the delivery of psychological services without requiring a mental health diagnosis for an individual whose problem is actually a physical illness. Importantly, Federal reimbursement for these codes will come out of funding for medical rather than psychiatric services and thus will not draw from limited mental health dollars. Allowing psychological services to be reimbursed from the physical health side of the reimbursement system acknowledges the importance of these services in addressing patients' physical health.

96150 – the initial assessment of the patient to determine the biological, psychological, and social factors affecting the patient’s physical health and any treatment problems.

96151 – a re-assessment of the patient to evaluate the patient’s condition and determine the need for further treatment. A re-assessment may be performed by a clinician other than the one who conducted the patient’s initial assessment.

96152 – the intervention service provided to an individual to modify the psychological, behavioral, cognitive, and social factors affecting the patient’s physical health and well being. Examples include increasing the patient’s awareness about his or her disease and using cognitive and behavioral approaches to initiate physician prescribed diet and exercise regimens.

96153 – the intervention service provided to a group. An example is a smoking cessation program that includes educational information, cognitive-behavioral treatment and social support. Group sessions typically last for 90 minutes and involve 8 to 10 patients.

96154 – the intervention service provided to a family with the patient present. For example,
a psychologist could use relaxation techniques with both a diabetic child and his or her parents to reduce the child’s fear of receiving injections and the parents’ tension when administering the injections.

96155 – the intervention service provided to a family without the patient present. An example would be working with parents and siblings to shape the diabetic child’s behavior, such as praising successful diabetes management behaviors and ignoring disruptive tactics.

Until now, almost all intervention codes used by psychologists involved psychotherapy and required a mental health diagnosis, such as under the DSM-IV. In contrast, health and behavior assessment and intervention services focus on patients whose primary diagnosis is physical in nature.

The codes capture services addressing a wide range of physical health issues, such as patient adherence to medical treatment, symptom management, health-promoting behaviors, health-related risk-taking behaviors, and overall adjustment to physical illness. In almost all of these cases a physician will already have diagnosed the patient’s physical health problem. Physical health diagnoses are typically represented by ICD-9 CM codes (see www.mcis.duke.edu/standards/termcode/icd9/1tabular.html or www.cdc.gov/nchs/icd9.htm).

If a psychologist is treating a patient with both a physical and mental illness he or she must pay careful attention to how each service is billed. The health and behavior codes cannot be used for psychotherapy services addressing the patient’s mental health diagnosis nor can they be billed on the same day as a psychiatric CPT code. The psychologist must report the predominant service performed.

Use of the codes will enable reimbursement for the delivery of psychological services for an individual whose problem is a physical illness and does not have a mental health diagnosis.

When providing outpatient care to Medicare beneficiaries, services for these patients will be reimbursed at a higher rate than psychotherapy because under current Federal regulations, the outpatient mental health treatment limitation does not apply to these new services (it only applies to services provided to patients with a mental, psychoneurotic, or personality disorder identified by an ICD-9 CM diagnosis code between 290 and 319).

Federal reimbursement for the health and behavior assessment and intervention codes will come out of funding for medical rather than psychiatric services and will not draw from limited mental health dollars. For private third party insurance we expect these services to be treated under the physical illness benefits of a plan and thus not be subjected to the higher outpatient consumer co-payment found in Medicare or relegated to behavioral health “carve out” provisions.

The codes and their assigned relative values used for calculating Medicare fees are listed in the 2002 physician fee schedule issued by the Centers for Medicare and Medicaid Services (CMS) in the November 1, 2001 Federal Register. Each code is based on 15 minutes of service so a psychologist would bill 2 units when providing a 30-minute service. When the service falls between units you must round up or down to the nearest increment. To illustrate, a psychologist would bill 3 units for a 50-minute service but would bill 4 units for a 55-minute service.

Illustrated below are estimated Medicare reimbursement amounts for 2002. Psychologists should check with their local Medicare carriers for the exact payment rates in their geographic area.

CPT Code	Service	Approximate Medicare Payment (15 min – 1 unit)	Approximate Medicare Payment (1 hr – 4 units)
96150	Assessment – initial	$ 26*	$ 106*
96151	Re-assessment	$ 26	$ 103
96152	Intervention – individual	$ 25	$ 98
96153	Intervention – group (per person)	$ 5**	$ 22**
96154	Intervention – family w/ patient	$ 24	$ 96
96155	Intervention – family w/o patient	$ 23	$ 93

* Multiple-unit differences are due to rounding
** Total group fee equals amount times number of persons in group

There are two new codes for assessment services used to identify the biological, psychological and social factors important to the prevention, treatment or management of physical health problems. One code, 96150, is for an initial health and behavior assessment while 96151 should be used when reassessing a previously assessed patient. An example of an initial assessment service under 96150, developed as part of the APA proposal submitted to the CPT committees for approval of the new codes, would be:

A 5-year old boy undergoing treatment for acute lymphoblastic leukemia is referred for assessment of pain and severe behavioral distress associated with repeated lumbar punctures and chemotherapy. Previously unsuccessful approaches (pharmacologic treatment and conscious sedation) only exacerbated the child's distress.

The patient is assessed using standardized questionnaires (e.g., Pediatric Pain Questionnaire, Information-Seeking Scale) administered in a structured format. The medical staff and the child's parents are also interviewed. On the day of a scheduled medical procedure, the child completes a self-report distress questionnaire and behavioral observations are made during the procedure. An assessment of the patient's condition is performed through the use of various health and behavior assessment instruments. The focus of the assessment is on the biological, psychological, and social factors affecting the physical health and treatment problems of the child. It is not the assessment of a mental health condition.

Code 96151 allows for the re-assessment of a patient who has already undergone an initial assessment. It is important to note that a re-assessment may or may not be conducted by the clinician that conducted the initial assessment of the patient. An example of a re-assessment service is:

A 35-year old female with a diagnosis of chronic asthma, hypertension and panic attacks is seen for assessment and follow-up treatment. The original assessment includes an extensive interview regarding the patient's emotional, social and medical history, including her ability to manage problems related to chronic asthma, hospitalizations and treatments. After four months of treatment interventions, the patient's hypertension and anxiety are significantly reduced and the patient is discharged.

Six months after discharge the patient injures her knee and undergoes arthroscopic surgery with follow-up physical therapy. The psychologist sees the patient to reassess and evaluate the psychophysiological responses to the new medical interventions. The psychologist performs a re-assessment of the patient's condition through the use of interview and behavioral health instruments. The psychologist administers an anxiety inventory questionnaire to qualify the patient's current level of response to present health stressors. The psychologist compares the results to the patient's original assessment levels and evaluates the need for further treatment.

The four new intervention codes reflect services used to modify the psychological, behavioral, cognitive, and social factors affecting a patient's physiological functioning, health and well being. The codes apply to intervention services for (1) an individual, (2) a group, (3) a family with the patient present and (4) a family without the patient present. For example, an intervention service for an individual would be:

A 55-year old executive has a history of cardiac arrest, high blood pressure and cholesterol, and a family history of cardiac problems. He is 30 lbs. overweight, smokes one-half pack of cigarettes a day and is a moderate social drinker. The patient's physician considers him to be a "Type A" personality and at high risk for cardiac complications. He experiences angina pain one or two times per month.

The psychologist uses results from a health and behavior assessment to develop a treatment plan, taking into account the patient's coping skills and lifestyle. The treatment plan involves weekly intervention sessions that focus on psychoeducational factors to increase the patient's awareness and knowledge about his disease process. The psychologist uses relaxation and guided imagery techniques to directly impact the patient's blood pressure and heart rate. The psychologist also utilizes cognitive and behavioral approaches for cessation of smoking and initiation of an appropriate physician-prescribed diet and exercise regimen.

The success of these new codes will depend in large part upon how frequently they are used by psychologists. Because CPT code descriptors do not limit the services to any particular profession, other licensed health care professionals whose scope of practice allows them to perform services that fall within the descriptors may also bill these codes. Under the AMA's coding process, the specialty society for the health care profession that most frequently bills a code is considered the "lead" organization and as such conducts any surveys of the codes and speaks on behalf of all others when the code is under review. As the specialty society that developed the health and behavior codes, APA has taken the lead on all activities involving these codes. In the future, however, APA will retain control only if psychologists make use of the codes more frequently than other licensed health care professionals do.

The extent to which psychologists use these codes will also weigh heavily in determining future "work values" which are the values assigned to reflect the health care professional's time and effort in providing the service. It is common for new codes to begin with relatively low work values but then have the values raised as more data is obtained about the services performed. The health and behavior codes have work values that are roughly 80% of psychotherapy but these values can improve as the profession accumulates experience with their usage. Because psychologists' services are usually valued higher than those of other non-physician practitioners, the more psychologists use these codes, the greater the likelihood that higher values will be reflected in future surveys of professional work. Greater work values have clear implications for reimbursement rates.

Development of the codes took several years and involved the combined efforts of the Interdivisional Healthcare Committee and APA's Practice Directorate. In the latter stages, APA members Dr. Antonio Puente and Dr. Jim Georgoulakis shepherded the codes through various AMA committees.

The new codes are listed in the 2002 physician fee schedule issued by the Centers for Medicare and Medicaid Services (CMS) in the November 1, 2001 Federal Register. The codes are based on 15 minutes of service. To illustrate, a psychologist furnishing an individual with 45 minutes of intervention services would bill for 3 units.

Determining reimbursement requires a calculation involving various factors including geographic adjustments. Local insurance carriers are now being updated by CMS and should now have information on the exact reimbursement amounts. Members should be aware that problems might arise when the codes first become effective. There has already been one case where a carrier mistakenly labeled the codes as preventive services and presumed Medicare would not cover them. Government Relations notified CMS of this mistake and the agency is now taking action to correct it.