Many digital therapeutics (DTx) providers are working to obtain reimbursement from U.S. payers. The following post discusses stategy for reaching patients and partnerships. A reputable DTx company will have a strategy for reaching patients considering whether the therapeutic is curative or designed for chronic care.
Digital therapeutics (DTx) represent a novel approach to delivering improved clinical outcomes, but the unstructured nature of today’s DTx access process has presented a major hurdle to broader uptake
Payers are still at very different stages in their acceptance of DTx, and in contrast with traditional pharmaceuticals, buy-in from senior leadership will be an essential part of the top-down decision-making process for DTx prioritization
Pharmacy benefit managers (PBMs) have taken a leadership role in facilitating a pathway for digital therapeutics adoption, and they are likely to remain the optimal entry point for DTx coverage and reimbursement in the near term
Employer groups are likely to be early advocates for the benefits of DTx after running individual pilot programs, whereas managed care organizations (MCOs) may be less receptive to covering DTx until a national body of real-world evidence becomes available
Ultimately, payers still have limited willingness to pay for DTx that lack clear impact on plan expenditures, and they will expect to see risk-sharing contracts on the table that can address these uncertainties
PAYER REIMBURSEMENT
More developed DTx companies are coming to discover that payer acceptance and reimbursement is key to market viability and that preparations to engage payer support need to be made in the development stage. Typically, companies partner with pharma companies to leverage traditional insurance reimbursement and distribution pathways, as in the case of Pear Therapeutics benefiting from its partnership with Sandoz. However, are seeking alternative payer reimbursement pathways, looking instead to pharmacy benefit management plans or distributing directly to patients through employers as additional benefit programs.
PHYSICIAN ADOPTION As the oldest of the DTx have begun to mature, physician adoption is the final hurdle to consumer adoption. There are three major approaches to gaining physician adoption. Pear Therapeutics is using the pharmaceutical model, leveraging pharmaceutical distribution partnerships to make physicians aware of and willing to prescribe the product. Better Therapeutics, which develops a product for insomnia, is partnering with a pharmacy benefit plan that specifically offers a digital dispensary – effectively curating benefit-covered products in a single platform that physicians can use when making therapeutic recommendations. Kaia Health is taking a less traditional approach – the company has been targeting physicians as part of a marketing campaign, but the app is on the App Store and offers three subscription packages for patients.
Physical therapist services are generally covered as a basic benefit by all major health insurance companies. Ask your physical therapist to contact your insurance company to determine your specific benefits.
Physical therapist services are generally covered as a basic benefit by all major health insurance companies. Ask your physical therapist to contact your insurance company to determine your specific benefits.
CAN I RECEIVE PHYSICAL THERAPY SERVICES WITHOUT A PHYSICIAN’S REFERRAL?
Consumers are not required to have a referral or diagnosis in order to receive physical therapist services in the State of California. Physical therapist services may be obtained without a physician’s referral if you are a cash carrying patient, receiving treatment for up to 45 calendar days/12 visits, receiving health and wellness services, or if you are a UnitedHealthCare or Medicare beneficiary.
Please note: some health insurance companies require a referral in order for your provider to be paid. Please confirm your benefit requirements by reviewing your coverage documents or calling member services of your respective insurance company. The contact number to your insurance company is listed on the back of your health insurance identification card.
The California Physical Therapy Practice Act requires all licensed physical therapists to disclose (in writing) the following information to all consumers receiving physical therapist treatment without a physician or surgeon referral or diagnosis:
Under California law, you may continue to receive direct physical therapy treatment services for a period of up to 45 calendar days or 12 visits whichever occurs first.
Under California law, you may continue to receive direct physical therapy treatment services for a period of up to 45 calendar days or 12 visits, whichever occurs first, after which time a physical therapist may continue providing you with physical therapy treatment services only after receiving, from a person holding a physician and surgeon’s certificate issued by the Medical Board of California or by the Osteopathic Medical Board of California, or from a person holding a certificate to practice podiatric medicine from the California Board of Podiatric Medicine and acting within his or her scope of practice, a dated signature on the physical therapist’s plan of care indicating approval of the physical therapist’s plan of care and that an in-person patient examination and evaluation was conducted by the physician and surgeon or podiatrist.
Antisocial Personality Disorders and Implications on Business Operations: Corporate Psychopathology as a Human Resources Agenda Item
Publication description
The ability of a leader to understand, and level with, employees’ emotions can be a vital determinant in business performance and employee morale. Emotional intelligence, as a construct, is a dynamic mitigating element in buffering the myriad of business challenges amid the unique demands of a workforce comprised of human beings and operational problem solving involved in navigating the modern healthcare climate. The absence of emotional capacity within a leader, on the other hand, can be significantly deleterious to business operations.
This paper will discuss a particular subset of personality disorder manifestation in the workplace, namely antisocial personality disorder (APD), the implications of APD on business operations and colleagues, recommendations as to the methods human resources can deploy to mitigate the impact of such factors, and postulates mindfulness meditation as a workplace wellness strategy which can buffer the negative effects of APD manifestation and promote mental wellbeing in the workforce.
While emotional intelligence is on a spectrum and can be associated with business outcomes in a direct correlation (Mandell & Pherwani, 2003), it is worth discussing the implications of pathology in emotional processing as it pertains to the workforce—particularly in management.
Agenda Managed Care 101 for healthcare entrepreneurs seeking to do business in the California market.
Healthcare flow of funds explained. Managed Care 101 for healthcare entrepreneurs seeking to do business in the California market. Session led by Alex Yarijanian, CEO Carenodes. The aim: providing healthcare entrepreneurs with a framework within which they will find their place in the business value chain.
No business doing business in healthcare.
No business doing business in healthcare if you don’t know healthcare business. With that said, you shouldn’t limit yourself because you might have value to contribute. But it should worry you because you don’t have the time necessary to gain tribal, on-the-job, healthcare know-how and work experience.
This session challenges the idea that, just because you don’t have healthcare experience, you can’t learn if knowledge is transmitted in uniquely effective styles and methods.
Providing healthcare entrepreneurs with a framework within which they will find their place in the healthcare business value-chain.
Crossing the Chasm of Healthcare Startups: Reduce go-to-market time by understanding your leverqage points vis a vie industry meta-dynamics and insider insight. Bend the learning curve that surprises, paralyzes, and discourages many health technology startups.
Crossing the Chasm of Healthcare Startups: Reduce go-to-market time by understanding your leverage points vis a vie industry meta-dynamics and insider insight. Bend the learning curve that surprises, paralyzes, and discourages many health technology startups.
Managed Care Boot-camp for Healthcare Entrepreneurs, was a ‘pilot’ session designed to impart otherwise difficult to synthesize knowledge. Given its ‘pilot’ nature, please excuse instances where your experience might be interrupted by factors such as difficulty in whiteboard visibility, etc.
BOOTCAMP SESSION EXPERIENCE & OUTCOMES
Everyone should be able to walk out of this session feeling empowered by having learned the basic flow of funds (starting at the payer) and reimbursement structures along the healthcare delivery value chain.
Managed Care Boot-camp for Healthcare Entrepreneurs, a ‘pilot’ session designed to impart otherwise difficult to synthesize knowledge with the following objectives:
1. Bend the learning curve of entrepreneurs in healthcare 2. Provide a framework to contextualize health tech business models (aim: to help provide a framework within which you will find your place in the business value chain).
You should be able to better refine your understanding of what ‘buckets’, and mechanisms, of funding you should pursue and trigger so as to index your business accordingly. Trends, current industry practices, and changes set to be effective in the future will be weaved into the session so as to contextualize the material.
E&M Coding Advice
Physicians and Medicare alike have struggled for many years with correct coding, documentation, and payment of evaluation and management (E&M) services. That’s because, by their nature, E&M services are a diverse set of cognitive procedu
Physicians and Medicare alike have struggled for many years with correct coding, documentation, and payment of evaluation and management (E&M) services. That’s because, by their nature, E&M services are a diverse set of cognitive procedures, making them difficult to quantify.
Carenodes medical executives offer the following highly simplified but useful “bottom-line” E&M coding advice.
Regardless of how much history, physical examination, and/or medical decision-making related to an E&M encounter are recorded.
Do not consider reporting the highest two codes of any code family:
When fewer than three distinct medical conditions/complaints were evaluated and managed during the encounter, OR
No problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability, or death between the time of the current encounter and the next physician encounter.
Do not consider reporting the highest codes of any code family:
When fewer than four distinct medical conditions/complaints were evaluated and managed during the encounter, OR
No problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability, or death between the time of that encounter and the next physician encounter.
This approach simplifies coding E&M services by eliminating from consideration the highest-level codes for reporting services that – by their clinical nature – usually do not require a detailed or comprehensive history and physical, high- (and sometimes moderate-) complexity medical decision making, or lengthy counseling and coordination. It addresses the most common source of known Medicare E&M coding errors: failure of medical records to demonstrate the work of and/or medical necessity of higher level E&M services reported for payment.
E&M Coding Advice
Physicians and Medicare alike have struggled for many years with correct coding, documentation, and payment of evaluation and management (E&M) services. That’s because, by their nature, E&M services are a diverse set of cognitive procedu
Physicians and Medicare alike have struggled for many years with correct coding, documentation, and payment of evaluation and management (E&M) services. That’s because, by their nature, E&M services are a diverse set of cognitive procedures, making them difficult to quantify.
The Carenodes medical executives offer the following highly simplified but useful “bottom-line” E&M coding advice.
Regardless of how much history, physical examination, and/or medical decision-making related to an E&M encounter are recorded.
Do not consider reporting the highest two codes of any code family:
When fewer than three distinct medical conditions/complaints were evaluated and managed during the encounter,
OR
No problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability, or death between the time of the current encounter and the next physician encounter.
Do not consider reporting the highest codes of any code family:
When fewer than four distinct medical conditions/complaints were evaluated and managed during the encounter,
OR
No problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability, or death between the time of that encounter and the next physician encounter.
This approach simplifies coding E&M services by eliminating from consideration the highest-level codes for reporting services that – by their clinical nature – usually do not require a detailed or comprehensive history and physical, high- (and sometimes moderate-) complexity medical decision making, or lengthy counseling and coordination. It addresses the most common source of known Medicare E&M coding errors: failure of medical records to demonstrate the work of and/or medical necessity of higher level E&M services reported for payment.
If you have not updated your practice’s fee schedule for several years, you may be in for some surprises. Carenodes Advisory recommends that you analyze and update your fees annually to make sure they are higher than insurance allowables.
If you have not updated your practice’s fee schedule for several years, you may be in for some surprises. Carenodes Advisory recommends that you analyze and update your fees annually to make sure they are higher than insurance allowables.
Remember, insurers typically will pay you either their allowable or your fee – whichever is lower. By charging less than the allowable, you are not getting the maximum reimbursement you are entitled to receive. If you are receiving 100 percent of your billed charge from a managed care plan, this could indicate your fee is set too low.
Many commercial plans base their fees on Medicare reimbursement, making it easier for you to evaluate their reimbursement patterns. As Medicare publishes its new fee schedule each year, you have an opportunity to compare your own fees against the new rates. At the same time, you can make revenue projections for the coming year and assess the value of your managed care contracts to your practice.
Sample Letter (SB 418): Paper Claim in Process over 45 days
Dear Payer: Please be advised that this letter is to request final resolution of the claim/services in question. … We are aware that the Texas Prompt Payment law (28 TAC §§21.2801 – 21.2824) p
TO: [PAYER]
____________________
____________________
____________________
____________________
RE: Request for Claim Resolution
Patient: _______________________
Member ID: ____________________
Insured: _______________________
Date of Service: _________________
Amount: _______________________
Dear Payer:
Please be advised that this letter is to request final resolution of the claim/services in question.
It is believed that your organization has had the paper-submitted clean claim(s) in question pending and in your possession for 45 or more calendar days. All data elements required by Texas Law were present on the claim(s) when submitted.
We believe that failure to release payment may be a violation of Texas law.
We are aware that the Texas Prompt Payment law (28 TAC §§21.2801 – 21.2824) prohibits insurers from unnecessarily delaying claims processing. Payers have 45 days to (1) pay the total amount of a clean claim in accordance with its provider contract, (2) pay the undisputed portion and notify the provider in writing why the rest won’t be paid or (3) notify the provider in writing why the claims will not be paid.
If a carrier is unable to pay or deny a paper claim within 45 days, in whole or in part, and audits the claim to determine whether the claim is payable, the payer must notify the physician that the claim is being audited and pay 100% of the contracted rate.
Payers that violate these requirements are liable to a provider a graduated penalty in addition to the contracted rate and may be subject to an administrative penalty by the Texas Department of Insurance.
Since the paper claim(s) in question were received by your company over 45 days ago, we are requesting the following at this time:
For claims paid up to 45 days late, the contracted rate plus the lesser of 50% of the difference between the billed charges and the contracted rate or $100,000; or,
For claims paid 46-90 days late, the contracted rate plus the lesser of 100% of the difference between the billed charges and the contracted rate or $200,000; or,
For claims paid more than 90 days late, the contracted rate plus the lesser of 100% of the difference between the billed charges and the contracted rate or $200,000, plus 18% annual interest on the penalty amount.
Thank you for your prompt attention to this matter. Should you have any questions, please contact our office at ____________________________.
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.
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.
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-10 CM codes (see the CDC website).
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 (90785-90899). 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.
Health Behavior Assessment and/or Intervention (HBAI)
“Health and Behavior Assessment procedures are used to identify the psychological, behavioral, emotional, cognitive, and social factors important to the prevention, treatment or management of physical health problems. The focus of the assessment is not on mental health but on the biopsychosocial factors important to physical health problems and treatments.” 1
Health and Behavior Intervention procedures are used to modify the psychological, behavioral, emotional, cognitive, and social factors directly affecting the patient’s physiological functioning, health and well being, or specific disease-related problems.
Indications:
For dates of service prior to 01/01/2020, the Health and Behavioral Assessment, initial (CPT code 96150) and Reassessment (CPT code 96151), and Intervention services (CPT codes (96152-96153) may be considered reasonable and necessary for the patient who meets all of the following criteria:
For dates of service on or after 01/01/2020, the Health and Behavioral Assessment, initial and Reassessment should be reported with CPT code 96156, and Intervention services should be reported with CPT codes 96158, 96159, 96164, 96165.
The patient has an underlying physical illness or injury, and
There are indications that biopsychosocial factors may be significantly affecting the treatment or medical management of an illness or an injury, and
The patient is alert, oriented and has the capacity to understand and to respond meaningfully during the face-to-face encounter, and
The patient has a documented need for psychological evaluation or intervention to successfully manage his/her physical illness, and activities of daily living, and
The assessment is not duplicative of other provider assessments
In addition, for a reassessment to be considered reasonable and necessary, there must be documentation that there has been a sufficient change in the mental or medical status warranting re-evaluation of the patient’s capacity to understand and cooperate with the medical interventions necessary to their health and well being.
Health and Behavioral Intervention, individual or group (2 or more patients) (CPT codes 96152-96153 (for dates of service prior to 01/01/2020) and CPT codes 96158, 96159, 96164, 96165 (for dates of service on or after 01/01/2020) require that:
Specific psychological intervention(s) and patient outcome goal(s) have been clearly identified, and
Psychological intervention is necessary to address:
Non-compliance with the medical treatment plan, or
The biopsychosocial factors associated with a new diagnosed physical illness, or an exacerbation of an established physical illness, when such factors affect symptom management and expression, health-promoting behaviors, health-related risk-taking behaviors, and overall adjustment to medical illness.
Health and Behavioral Intervention (with the family and patient present) (CPT codes 96154/96153 (for dates of service prior to 01/01/2020) and CPT codes 96167, 96168 (for dates of service on or after 01/01/2020) is considered reasonable and necessary for the patient who meets all of the following criteria:
The family representative* directly participates in the overall care of the patient, and
The psychological intervention with the patient and family is necessary to address biopsychosocial factors that affect compliance with the plan of care, symptom management, health-promoting behaviors, health-related risk-taking behaviors, and overall adjustment to medical illness.
*For the purpose of this policy, all references to a family representative is defined as immediate family members only (i.e., husband, wife, siblings, children, grandchildren, grandparents, mother, and father), any primary caregiver who provides care on a voluntary, uncompensated, regular and sustained basis, or a guardian or healthcare proxy.
Limitations:
Health and Behavioral Assessment/Intervention will not be considered reasonable and necessary for the patient who:
Does not have an underlying physical illness or injury, or
For whom there is no documented indication that a biopsychosocial factor may be significantly affecting the treatment, or medical management of an illness or injury (i.e., screening medical patient for psychological problems), or
Does not have the capacity to understand and to respond meaningfully during the face to face encounter, because of:
Dementia that has produced a severe enough cognitive defect for the psychological intervention to be ineffective.
disorientation to person, time, place, purpose, or
inability to recall current season, location of own room, names and faces, or
inability to recall that he or she is in a nursing home or skilled nursing facility
Does not require psychological support to successfully manage his/her physical illness through identification of the barriers to the management of physical disease and activities of daily living, or
For whom the conditions noted under the indications portion of this section are not met.
Health and Behavioral Intervention with the family and patient present will not be considered reasonable and necessary for the patient if:
It is not necessary to ensure patient compliance with the medical treatment plan, or
The family representative does not directly participate in the plan of care, or
The family representative is not present.
There is no face to face encounter with the patient.
Because it does not represent a diagnostic or treatment service to the patient, there is no coverage for CPT code 96155. Effective for dates of service on or after 01/01/2020, CPT code 96155 has been deleted and replaced with CPT codes 96170, 96171.
Health and Behavioral Intervention services are not considered reasonable and necessary to:
Update or educate the family about the patient’s condition
Educate family members, primary care-givers, guardians, the health care proxy, or other members of the treatment team, e.g., health aides, nurses, physical or occupational therapists, home health aides, personal care attendants and co-workers about the patient’s care plan.
Assist in treatment-planning with staff
Provide family psychotherapy or mediation
Educate diabetic patients and diabetic patients’ family members
Deliver Medical Nutrition Therapy
Maintain the patient’s or family’s existing health and overall well-being
Provide personal, social, recreational, and general support services. Although such services may be valuable adjuncts to care, they are not medically necessary psychological interventions.
Examples of services not covered as health and behavioral interventions are:
Stress management for support staff
Replacement for expected nursing home staff functions
Music appreciation and relaxation
Craft skill training
Cooking classes
Comfort care services
Individual social activities
Teaching social interaction skills
Socialization in a group setting
Retraining cognition due to dementia
General conversation
Services directed toward making a more dynamic personality
Consciousness raising
Vocational or religious advice
General educational activities
Tobacco or caffeine withdrawal support
Visits for loneliness relief
Sensory stimulation
Games, including bingo games
Projects, including letter writing
Entertainment and diversionary activities
Excursions, including shopping outings, even when used to reduce a dysphoric state
Teaching grooming skills
Grooming services
Monitoring activities of daily living
Teaching the patient simple self-care
Teaching the patient to follow simple directives
Wheeling the patient around the facility
Orienting the patient to name, date, and place
Exercise programs, even when designed to reduce a dysphoric state
Memory enhancement training
Weight loss management
Case management services including but not limited to planning activities of daily living, arranging care or excursions, or resolving insurance problems
Activities principally for diversion
Planning for milieu modifications
Contributions to patient care plans
Maintenance of behavioral logs
Biofeedback is coded as 90901 and will not be covered as a health and behavioral intervention.
Coding Information:
Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.
The diagnosis code(s) must describe the patient’s condition for which the service was performed.
Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.
CPT codes 96150-96154 may be used only by a Clinical Psychologist (CP), (Specialty Code 68). Effective for dates of service on or after 01/01/2020, CPT codes 96150-96154 have been deleted and replaced with CPT codes 96156, 96167, 96168.
If the initial health and behavior assessment or reassessment (CPT codes 96150-96151) is unable to be completed during a single encounter, the date of service indicated on the claim should be the date on which the interview was finalized. Effective for dates of service on or after 01/01/2020, CPT codes 96150-96151 have been deleted and replaced with CPT code 96156.
For health and behavior assessment and/or intervention services performed by a physician, clinical nurse specialist (CNS), or nurse practitioner (NP), Evaluation and Management (E&M) or Preventive Medicine services codes should be used.
Services to patients for evaluation and treatment of mental illnesses should be coded using a psychiatric services CPT code (90801-90899).
For patients that require psychiatric services (CPT codes 90801-90899) as well as health and behavior assessment/intervention (96156, 96167, 96168), report the predominant service performed.
Do not report CPT codes 96150-96154 in addition to CPT codes 90801-90899 on the same date. CPT code 96155 is not a covered service. Effective for dates of service on or after 01/01/2020, CPT codes 96150-96154 have been deleted and replaced with CPT code 96156, 96167, 96168 and CPT code 96155 has been deleted and replaced with CPT codes 96170, 96171.
Group 1 Codes:
CODE
DESCRIPTION
96156
HEALTH BEHAVIOR ASSESSMENT, OR RE-ASSESSMENT (IE, HEALTH-FOCUSED CLINICAL INTERVIEW, BEHAVIORAL OBSERVATIONS, CLINICAL DECISION MAKING)
96158
HEALTH BEHAVIOR INTERVENTION, INDIVIDUAL, FACE-TO-FACE; INITIAL 30 MINUTES
96159
HEALTH BEHAVIOR INTERVENTION, INDIVIDUAL, FACE-TO-FACE; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)
96164
HEALTH BEHAVIOR INTERVENTION, GROUP (2 OR MORE PATIENTS), FACE-TO-FACE; INITIAL 30 MINUTES
96165
HEALTH BEHAVIOR INTERVENTION, GROUP (2 OR MORE PATIENTS), FACE-TO-FACE; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)
96167
HEALTH BEHAVIOR INTERVENTION, FAMILY (WITH THE PATIENT PRESENT), FACE-TO-FACE; INITIAL 30 MINUTES
96168
HEALTH BEHAVIOR INTERVENTION, FAMILY (WITH THE PATIENT PRESENT), FACE-TO-FACE; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)
96170
HEALTH BEHAVIOR INTERVENTION, FAMILY (WITHOUT THE PATIENT PRESENT), FACE-TO-FACE; INITIAL 30 MINUTES
96171
HEALTH BEHAVIOR INTERVENTION, FAMILY (WITHOUT THE PATIENT PRESENT), FACE-TO-FACE; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)
CPT codes 96170, 96171 are not a covered services. Group 1 Codes.
The patient’s medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See “Indications and Limitations of Coverage.”) This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. Claims submitted without ICD-10-CM codes will be returned.
Because of the impact on the medical management of the patient’s disease, documentation must show evidence of coordination of care with the patient’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.
Documentation in the medical record by the Clinical Psychologist (CP) (Specialty Code 68) must include:
a. For the initial assessment, evidence to support that the assessment is reasonable and necessary, and must include, at a minimum, the following elements:
Health and Behavioral Assessment/Intervention (CPT codes 96150-96154) may only be performed by a Clinical Psychologist (CP-Specialty Code 68). Effective for dates of service on or after 01/01/2020, CPT codes 96150-96154 have been deleted and replaced with CPT code 96156, 96167, 96168.
Date of initial diagnosis of physical illness, and
Clear rationale for why assessment is required, and
Assessment outcome including mental status and ability to understand and respond meaningfully, and
Goals and expected duration of specific psychological intervention(s), if recommended.
b. For re-assessment, detailed progress notes to support that the reassessment is reasonable and necessary must include the following elements:
Date of change in mental or physical status
Sufficient rationale for why re-assessment is required, and,
Clear indication of any precipitating events that necessitate re-assessment
c. For the intervention service, evidence to support that the intervention is reasonable and necessary must include, at a minimum, the following elements:
Evidence that the patient has the capacity to understand and to respond meaningfully
Clearly defined psychological intervention planned
The goals of the psychological intervention
There expectation that the psychological intervention will improve compliance with the medical treatment plan
The response to the intervention
Rationale for frequency and duration of services
For all claims, the time duration (stated in minutes) spent in the health and behavioral assessment or intervention encounter must be documented in the record.
Documentation must be available to Medicare upon request.
Sources of Information:
This bibliography presents those sources that were obtained during the development of this policy. National Government Services is not responsible for the continuing viability of Web site addresses listed below.
Current Procedural Terminology, CPT 2009
Program Memorandum, Expanded Coverage of Diabetes Outpatient Self-Management Training, CR 1455, June 15, 2001
Program Memorandum, Medical Nutrition Therapy for Beneficiaries with Diabetes or Renal Disease, CR 1776, August 7, 2001
Carrier Advisory Committee Psychiatry Working Group
CPT Changes, “An Insider’s View”, 2002, American Medical Association, pages 218-220.
Alex Yarijanian 