Behavioral health CPT codes for patients with a physical diagnosis & the New Integrated Care Paradigm

There are six reimbursement codes for health and behavior assessment and intervention. These codes apply to behavioral, social, and psychophysiological procedures for the prevention, treatment or management of physical health problems.

The health and behavior assessment and intervention codes

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.

How these services differ from psychotherapy

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.

If a mental health clinician 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 clinician 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. Since these codes are new, reimbursement rates from the private sector have not been determined. However, it is important that psychologists begin to use these codes now to accurately capture the services provided.

New codes to be paid with physical health dollars in Medicare

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). For example, Medicare would reduce the approved amount of a 45-minute outpatient psychotherapy session by 62.5% and then reimburse 80% of the remainder, resulting in a payment of approximately $48. In contrast, Medicare would reimburse a 45-minute outpatient health and behavior intervention for an individual at 80% of the approved amount, or approximately $59.

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.

What non-physician practitioners are eligible for Medicare Part B for reimbursement?

Non-physician practitioners who are authorized under Medicare Part B programs to furnish mental health services include clinical psychologists, clinical social workers, nurse practitioners, clinical nurse specialists, and physician assistants. Medicare does not pay marriage and family therapists or licensed professional counselors for their mental health services.

Here are the further developments:

First, Medicare now routinely reimburses H & B codes nationally, with the exception of Illinois and Wisconsin. However, the number of units allowed is often restricted.

Second, private payers are following Medicare’s lead and are also now reimbursing for H & B Codes. However, most payers, with the exception of United HealthCare, pay only for face-to-face treatment, not for chart review, report writing, etc.

Third, it is often difficult to get many private payers to authorize treatment for H & B services.  Mental health is often carved out by health plans and the contractual boundary between mental health and physical health is often not clear cut. The mental health carve out company, for instance, may not authorize care for treatment of a medical condition or diagnosis, and the medical insurer may not authorize care by non-medical providers. Thus, behavioral clinicians seeking reimbursement for these services are often are left having to petition the plan.

The good news is that progress toward care integration is advancing due to new technologies and reimbursement policies. The bad news is that America’s healthcare bureaucracy seems designed to make that advance as slow and difficult as possible.

The New Integrated Care Paradigm

A variety of forces are reshaping how behavioral healthcare is delivered in the US. These changes are due to a host of forces, among them:

-The Affordable Healthcare Act (more patients for behavioral clinicians)
-Parity (better reimbursement for behavioral clinicians)
-Focus on population based medicine
-Recognition that primary care is the de factor mental health system in America, i.e. the place where most behavioral healthcare is delivered
-That medical illness comes with much higher rates of depression and other psychiatric sequelae
-That behavioral interventions can assist patients better cope with chronic illness
-That costs can be contained through care coordination between behavioral and medical clinicians.

These changes are behind the movement toward a new model of behavioral healthcare delivery: integrated behavioral care. Integrated care involves the close

collaboration and coordination of care by the healthcare team to address physical and behavioral needs of the patient. It recognizes the central role of the primary

care (called the patient’s medical home), the need for behavioral interventions to treat not only psychiatric conditions but also to support and facilitate medical

treatment as well, and the focus on populations at risk. The big change in the delivery system in behavioral care is not so much where the care is delivered as how:

integrated care means close and ongoing coordination between medical and behavioral clinicians. Integrated behavioral care takes clinicians out of their silos and

situates them squarely on the healthcare treatment team.

Integrated behavioral care portends the end of the psychiatric “carve out” whereby mental health services are managed (and funded) separately from medical services. As

behavioral health services are “carved in” to the delivery system via integrated care, the culture of mental health service delivery will more closely resemble that of

other areas of medicine and will become more standardized, accountable and outcomes driven.

What does this mean for behavioral clinicians? It means that behavioral clinicians will transition from a primarily silo model where psychotherapy is largely outside

the mainstream healthcare delivery system, to one in which it is fully integrated. It means that clinicians will have to expand their repertoire of services to include

addressing medical illness issues, e.g. compliance, lifestyle coaching, etc. And it means that the electronic medical record (EMR) will become the clinician’s

workbench: communication with the treatment team, documentation, outcomes and accountability will derive from this technological platform.

Is this new model a challenge to behavioral clinicians. Yes. In the current mental health silo model, the clinician is sovereign and practices with a great deal of

privacy. In the world of behavioral integration, clinicians will be thrown into a healthcare fishbowl—their work will be visible and their and results will be measured

and public to the treatment team and the funders of care. Psychiatric EMRs will largely automate integration by automatically communicating with other treatment

providers via the Continuity of Care Document (basically a Diagnosis and Problem list), and by routinely collecting data for standardized reporting and outcomes

tracking. In short, behavioral healthcare will become accountable as never before.

In the next several years behavioral clinicians will need to figure out how they relate to the behavioral integration movement. Some will want to work in larger

medical systems as employees. However, many, perhaps most, clinicians will want to integrate with the medical system without losing their independence. Co-location is

one option for behavioral clinicians, but probably not feasible on a widespread basis. Remote collaboration is the more likely outcome with behavioral clinicians

serving as virtual treatment team members.

So what to do? In my view, behavioral clinicians ought to consider coming together to establish affiliation groups. These affiliations would be multidisciplinary

groups that cover all behavioral sub-specializations. The groups would provide a one-stop shop for medical groups and payers. They would use a common cloud-based, ONC

certified behavioral health EMR. The behavioral EMR would insure that confidential patient information that goes beyond the needs of the medical treatment team was

kept strictly confidential and did not “leak” into the larger medical record. The behavioral EMR would also, of necessity, be cloud-based so that interoperation

(communication) between medical and behavioral clinicians could be accomplished remotely, thereby enabling behavioral clinicians to be members of the treatment team,

albeit virtually. A referral widget could be provided to medical practices so that with one click a physician could quickly identify a suitable referral source, i.e.

clinician within a geographical area with the right sub-specialization, insurance panelling, etc.

The model I am describing is not organizationally top heavy. External inspection and control management—the model of the carve out—is replaced in the behavioral

integration model with internal management via information feedback and best practices. As a result more funding goes to care, less to costly administration.

It is not too soon for clinician’s to begin to build the behavioral healthcare system of tomorrow. Replacing behavioral health 1.0, the “carve out” model, with a

“carve-in” model—behavioral health 2.0—is long overdue. Already initiatives such as I have described are being created.

Update:
For a good summary of integrated care see this website for a comprehensive overview of integrated behavioral care see http://ibhp.org

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