CurrentEmpire BluecrossPolicy C-11003

Health and Behavior Assessment and Intervention Professional Reimbursement Policy

Governs reimbursement for health and behavior assessment and intervention services (CPT 96156-96171) for commercial members; applies when services are rendered by qualified non-physician behavioral health professionals and billed with a primary medical diagnosis. Affects providers submitting claims to Empire Bluecross (Anthem) under commercial plans.

Policy Summary

PayerEmpire Bluecross

PolicyHealth and Behavior Assessment and Intervention Professional Reimbursement Policy

Policy CodePolicy C-11003

Change TypeRevised — frequency limits moved from related policy

Effective DateMay 8, 2024

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines and are billed with a primary medical diagnosis when submitting HBAI codes.

SourceLink

POLICY UPDATE CHANGES

Moved frequency limits for CPT codes 96158-96159 and 96164-96165 from the Frequency Editing policy (C-08012) into the Related Coding section of this policy.

96156-96171CPT codes addressed

Frequency limits notedLimits for 96158-96159 and 96164-96165

Qualified non-physicianProvider requirement

Mental healthExcluded when primary dx

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Coverage Criteria

HBAI coverage criteria

Anthem allows separate reimbursement for Health and Behavior Assessment and Intervention (HBAI) codes when ALL of the following are met; separate reimbursement is not allowed in specified circumstances.

ALL of the following

Service rendered by a qualified non-physician behavioral healthcare professional.
Services are reported with a primary medical diagnosis of an acute or chronic physical illness.
Not separately reimbursed when
- Services are reported with a primary mental health or psychiatric diagnosis.
- Services are reported by a physician or other qualified healthcare professional who is licensed to report evaluation and management or preventive medicine services.

Billing and coding notes: Use CPT codes 96156-96171 as appropriate; add-on codes (e.g., 96159, 96165, 96168, 96171) must be used in conjunction with their primary service codes. Frequency limits apply as detailed in Related Coding (e.g., 96159 and 96165 up to 6 per date of service as add-ons; 96158 and 96164 limited to 1 per date of service).

Codes and Frequency Limits

HBAI codesCPTCovered

96156	Health behavior assessment; or re- assessment (i.e health-focused clinical interview, behavioral observations, clinical decision making).
96158	Health behavior intervention, individual, face - to-face; initial 30 minutes.
96159	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	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	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	Each additional 15 minutes (List separately).

Frequency limits — operational details for 96158-96159 and 96164-96165

96158 (individual, initial 30 min)Frequency limit: 1 per date of service.

96159 (individual, each additional 15 min; add-on)Use in conjunction with 96158; frequency limit: up to 6 per date of service.

96164 (group, initial 30 min)Frequency limit: 1 per date of service.

96165 (group, each additional 15 min; add-on)Use in conjunction with 96164; frequency limit: up to 6 per date of service.

Operational noteFrequency limits for CPT codes 96158-96159 and 96164-96165 were moved from the Frequency Editing policy (C-08012) into this policy's Related Coding section (effective 05/08/2024).

Authorization, Medical Necessity, and Billing Actions

Prior Authorization

Authorization, medical necessity, and billing responsibilities

Services must meet authorization and medical necessity guidelines and follow applicable state, federal, and contract mandates. Coverage is determined by the member's contract benefits in effect on the date services are rendered; providers must bill using industry-standard compliant codes and support billed services in the medical record or office notes.

Follow authorization and medical necessity requirements appropriate to the procedure, diagnosis, and member's state of residence.
Use Current Procedure Terminology (CPT), HCPCS, and/or revenue codes as required and ensure documentation in the medical record supports the billed services.
Be aware that state, federal, or contract mandates take precedence and may supersede this policy.

Definitions

Health and Behavior Assessment — definition

DefinitionThe evaluation of the patient's responses to disease, illness or injury, outlook, coping strategies, motivation, and adherence to medical treatment.

Typical componentsHealth‑focused clinical interview, behavioral observations, clinical decision making (per Related Coding descriptions).

Use caseSupports determination of behavioral contributors to medical conditions when billed with a primary medical diagnosis.

Health and Behavior Intervention — definition

DefinitionThe promotion of functional improvement; minimizing psychological and/or psychosocial barriers to recovery, and management of and improved coping with medical conditions.

GoalsPromote functional improvement and improve coping with medical conditions.