CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Health and Behavior Assessment and Intervention Services — Coverage Criteria

Coverage for health and behavior assessment and intervention services (CPT 96156–96171) when delivered by specified behavioral health providers; excludes use for primary psychiatric diagnoses and clarifies same‑day same‑provider billing interactions.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyHealth and Behavior Assessment and Intervention Services — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionDo not bill health and behavior assessment/intervention procedure codes for primary psychiatric diagnoses; when the same provider reports both psychiatric and health/behavior services on the same date, only the first submitted service will be paid.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

96156-96171covered CPT range

1copay rule

Not applicablePrior auth

Psychologists, LICSW, MFT, MHCcovered provider types

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Coverage Criteria

Covered services

Covered when provided by specified provider types and not billed for psychiatric diagnoses.

Provider qualifications and coding: Services are covered when provided by Psychologists (specialty code 062), Clinical Social Worker (LICSW) (specialty code 042), Family Therapist (MFT) (specialty code 078), or Mental Health Counselor (MHC) (specialty code 077).

From policy statement

Service codes: Coverage applies to CPT codes 96156, 96158–96171 as listed in the coding section.

From coding list

Diagnosis restriction: Health and behavior assessment/intervention services are invalid procedure codes (not member liability) if the diagnosis is for a psychiatric condition.

From coding section

Health and behavior assessment and intervention services (CPT codes 96156, 96158–96171) are not appropriate when the primary diagnosis is a psychiatric condition. The policy explicitly states that health and behavior assessment/intervention services are invalid procedure codes (not member liability) if the diagnosis is for a psychiatric condition, and such services must not be billed in place of psychiatric procedure codes for psychiatric diagnoses.

If services are determined to be not medically necessary (or are non-covered benefits), providers may not charge the member unless the member has been informed and has agreed in advance to continue treatment at their own expense. Providers should follow the applicable participation agreement provisions and verify member-specific benefits and eligibility before billing.

Coding and Time Units

Covered CPT CodesCPTCovered

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)

Service time units — billing increments

Initial unit lengthInitial service unit is 30 minutes (e.g., CPT codes 96158, 96164, 96167, 96170).

Additional unit incrementAdditional service time billed in 15-minute units (e.g., CPT codes 96159, 96165, 96168, 96171).

Billing instructionEach additional 15-minute unit is listed separately in addition to the primary service code.

Provider Actions and Billing Guidance

Prior Authorization

Not applicable

Denial Risk

Same-day, same-provider duplicate service denial

If psychiatric services and health and behavior services are rendered on the same date of service by the same provider, report the predominant service performed. If a health and behavioral assessment/intervention service and a psychiatric services procedure code are filed by the same provider for the same date of service, only the first submitted service (or the service with the predominant diagnosis) will be paid. The second service filed will be denied as a provider billing error.

Note

Benefit verification / member-specific coverage

Benefits and eligibility are determined by the member's subscriber agreement, member certificate, and/or the employer agreement; those documents supersede this medical policy. For member-specific benefits, contact the provider call center. Providers may not bill members for services determined to be not medically necessary or non-covered benefits unless the member was informed and agreed in writing in advance. Refer to your participation agreement for applicable provisions. BCBSRI may review and revise this policy at any time.

Background

Health and behavior assessment procedures are used to identify biopsychosocial factors—psychological, behavioral, emotional, cognitive, and social—that are important to the prevention, treatment, or management of physical health problems and procedures. The focus is on factors relevant to physical health rather than primary mental health diagnoses, which is why services in this code set are restricted when the diagnosis is psychiatric.

Definitions

Health and behavior assessment — definition and key points

DefinitionHealth and behavior assessment: procedures used to identify psychological, behavioral, emotional, cognitive, and social factors important to physical health problems and treatments; focus is not on primary mental health.

PurposeUsed to identify biopsychosocial factors important to prevention, treatment, or management of physical health problems.

Examples of procedure componentsMay include health-focused clinical interview, behavioral observations, and clinical decision making (associated with CPT 96156).

Service settings and formatsServices delivered individually, in groups, or family-based as specified by CPT codes 96156 and 96158–96171.

Coding note (actionable)These services are invalid procedure codes (not member liability) when billed with a psychiatric diagnosis—do not bill health and behavior codes for primary psychiatric conditions.

Health and Behavior Interventions

Health and behavior interventions

Modalities covered: Health behavior assessment and intervention services delivered individually, in groups, or family-based as specified by CPT codes 96156–96171.

From coding list