Currentpriority healthPolicy N/A

Psychological evaluation and management of non-mental health disorders

Covers health and behavioral assessment (96156) and intervention (96158-96159, 96164-96167) when provided by licensed clinicians as part of a comprehensive medical program to address biopsychosocial factors affecting physical illness; applies to Priority Health members per benefit plan.

Policy Summary

Payerpriority health

PolicyPsychological evaluation and management of non-mental health disorders

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2024

Next Review DateN/A

Key ActionInclude documented referral and coordination with the medical provider, ICD-10 diagnosis, assessment details, intervention plan with goals, time in minutes per encounter, and rationale for frequency/duration in the medical record.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

96156, 96158-59, 96164-65, 96167Primary CPT/HCPCS codes addressed

Licensed cliniciansAllowed provider types

No home settingLocation restriction

F01-F99, R45.x, R46.xICD-10 exclusions

Coverage Criteria

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inv-01: Initial Assessment and Intervention

Covered when ALL of the following are met:

Initial Assessment (96156) - ALL required: 1) underlying physical illness or injury; 2) reason to believe a biopsychosocial factor may be significantly affecting treatment or medical management; 3) member is alert, oriented, and has capacity to understand and to respond meaningfully during face-to-face encounter; 4) documented need for psychological support to successfully manage physical illness and activities of daily living; 5) assessment is not duplicative of other provider assessments

Supports reporting with a primary medical diagnosis; billed in 15-minute units.

Intervention (96158-96159; 96164-96165): Specific psychological intervention(s) and member outcome goals have been clearly identified AND intervention is necessary to address non-adherence with the medical treatment plan or biopsychosocial factors associated with a new or exacerbated physical illness when such factors affect symptom management, health-promoting behaviors, health-related risk-taking behaviors, or overall adjustment to medical illness

Group codes apply for two or more patients; services provided by licensed clinicians as part of a comprehensive medical program.

Family with patient present (96167): 1) family representative directly participates in the overall care of the member; 2) psychological intervention with the member and family is necessary to address biopsychosocial factors affecting adherence with the plan of care, symptom management, health-promoting behaviors, health-related risk-taking behaviors, and overall adjustment to medical illness

Family representative defined as immediate family, primary unpaid caregiver, guardian, or healthcare proxy.

inv-02: Reassessment

Re-assessment (96156) is reasonable and necessary when:

Reassessment criteria: Documentation indicates there has been a sufficient change in mental or medical status warranting re-evaluation OR the date of change and precipitating event are documented

See documentation requirements for required elements (coordination, rationale, goals, time in minutes per visit).

Services are considered not reasonable and necessary when they are provided to members who do not have an underlying physical illness or injury or when there is no documented indication that biopsychosocial factors are significantly affecting medical treatment or management. The policy excludes services for members who lack the capacity to engage meaningfully in a face-to-face encounter due to conditions such as dementia with severe cognitive defect, delirium, severe or profound cognitive impairment, persistent vegetative state, or other impaired mental status that prevents orientation and meaningful participation.

Health and behavior services that are primarily educational, administrative, or supportive rather than directly addressing biopsychosocial barriers to medical care are not covered. Examples include family education for non-immediate family or non-primary caregivers, teaching grooming or basic self-care skills, general conversation or social activities, staff education or treatment planning with staff, medical nutrition therapy, and activities principally for diversion (e.g., music appreciation, crafts, excursions, games).

Interventions that do not demonstrate a necessity for psychological support to successfully manage the member’s physical illness or activities of daily living are excluded. The policy specifically lists services that replace expected nursing or facility functions, vocational or religious advice, case management activities (arranging care or resolving insurance problems), and other recreational/social supports as not part of Health and Behavioral Intervention services and therefore not reasonable and necessary under this benefit.

Health and Behavioral Assessment and Intervention services are not medically necessary when the criteria in Section II.A are not met. Specifically, services are not medically necessary if the member does not have an underlying physical illness or injury, if there is no documented biopsychosocial factor affecting treatment or medical management, or if the member lacks the capacity to understand and respond meaningfully during the face-to-face encounter (for example, due to severe dementia, delirium, or profound cognitive impairment).

Coding

CPT/HCPCS Codes listedCPT

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-toface; initial 30 minutes
96168	Health behavior intervention, family (with the patient present), face-toface; each additional 15 minutes (List separately in addition to code for primary service) (not covered)
96170	Health behavior intervention, family (without the patient present), face-to-face; initial 30 minutes (not covered)
96171	Health behavior intervention, family (without the patient present), face-toface; each additional 15 minutes (List separately in addition to code for primary service)

ICD-10 codes that do not support medical necessityICD-10Not Covered

F01-F99	Mental, Behavioral and Neurodevelopmental disorders (do not support medical necessity)
R45.0-R45.89	Symptoms and signs involving emotional state (do not support medical necessity)
R46.0-R46.89	Symptoms and signs involving appearance and behavior (do not support medical necessity)

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization may be required for certain drugs, services, and procedures. When prior authorization is required, the provider must submit a request demonstrating that the drug, service, or procedure is medically necessary. Refer to the Priority Health Provider Manual for submission instructions and any form or portal requirements.

Submit prior authorization requests per Priority Health Provider Manual
Include supporting clinical information showing medical necessity

Note

Preserve source requirements: providers must follow the documented submission and coordination expectations in the policy text and supporting materials.

Follow Priority Health Provider Manual guidance for submission
Provide all requested documentation promptly upon request

Documentation Required

Required Documentation Elements

Documentation must demonstrate coordination of care with the member’s primary medical care provider or the medical provider responsible for the medical management of the physical illness addressed by the psychological assessment/intervention. Records must be maintained by the licensed clinician and made available to Priority Health upon request.

Evidence of referral for the initial assessment and each reassessment from the medical provider responsible for medical management
Evidence of coordination of care with the member’s primary medical care provider or the treating medical provider
Diagnosis with appropriate ICD-10-CM code indicating the reason for the service

Documentation Required

Clinical Documentation Details

Initial assessment (CPT 96156) documentation must include the date of initial diagnosis of the physical illness, a clear rationale for the assessment, assessment outcomes including mental status and capacity to participate, and goals/objectives and expected duration of recommended psychological interventions. Reassessment (CPT 96156) must document date of change in status, rationale for reassessment, and precipitating event. Intervention services (CPT 96158–96159) must document capacity to understand/respond, a defined intervention plan and goals tied to improving medical treatment compliance, response/progress, rationale for frequency/duration, and time in minutes for each visit.

Initial assessment (CPT 96156): date of initial physical diagnosis; rationale; assessment outcome; goals/objectives and expected duration
Reassessment (CPT 96156): date of status change; rationale; precipitating event
Intervention (CPT 96158–96159): capacity evidence; intervention plan and goals; linkage to medical treatment compliance; progress/response; frequency/duration rationale; visit duration in minutes
Medical records must be available upon request but need not be submitted with the claim

Denial Risk

Triggers for Denial / Not Reasonable and Necessary

Services will be considered not reasonable and necessary and may be denied when the member lacks an underlying physical illness or injury, when there is no documented indication that biopsychosocial factors significantly affect medical management, or when the member lacks capacity to participate meaningfully (for example: severe dementia, delirium, profound cognitive impairment, persistent vegetative state, or impaired orientation/recall as described in policy). Additional denial triggers include services provided when psychological support is not required to manage the physical illness, services that do not meet conditions in Section II, A, or family-focused interventions that are not necessary for member compliance or lack required family participation.

No underlying physical illness/injury documented
No documented biopsychosocial factor affecting treatment or medical management
Member incapable of meaningful participation (e.g., severe dementia, delirium, profound cognitive impairment, persistent vegetative state, impaired orientation/recall)
Services provided where psychological support is not required to manage the physical illness
Interventions that only update/educate family, train non-primary caregivers, mediate family disputes, or provide unrelated education (see limitations)

Background

Health and behavior assessments are clinical evaluations that identify psychological, behavioral, emotional, cognitive, and social factors that influence prevention, treatment, or management of physical health problems. These assessments focus on biopsychosocial elements that may affect physiological functioning or the medical management of acute or chronic conditions and inform whether targeted psychological interventions are indicated to improve adherence, symptom management, or health outcomes.

The assessment (CPT code 96156) and subsequent interventions (CPT codes such as 96158–96159, 96164–96167) are intended to be part of a comprehensive medical program. They support medical management by defining intervention goals tied to improving compliance and medical outcomes, documenting capacity to participate, and guiding treatment plans that address barriers to effective medical care.

Definitions

Health and Behavior Assessment / Intervention definitions — CPT codes

Assessment (CPT 96156)Focuses on biopsychosocial factors important to physical health; health‑focused clinical interview, behavioral observations, and clinical decision‑making to determine how psychological/behavioral factors affect medical management.

Individual intervention (CPT 96158, 96159)Psychological interventions delivered face‑to‑face to modify behavioral, emotional, cognitive, or social factors that directly affect physiological functioning or disease management; reported as initial 30 minutes (96158) and each additional 15 minutes (96159).

Group intervention (CPT 96164, 96165)Health behavior intervention provided face‑to‑face to two or more patients; reported as initial 30 minutes (96164) and each additional 15 minutes (96165).

Family with patient present (CPT 96167)Health behavior intervention delivered with the family and patient present to address biopsychosocial factors affecting adherence, symptom management, and adjustment to medical illness; initial 30 minutes (96167).

Scope of servicesServices target biopsychosocial factors that influence prevention, treatment, or management of physical health problems rather than primary mental health diagnoses.

Family representative definition

Immediate familyIncludes husband, wife, partner, siblings, children, grandchildren, grandparents, mother, and father.

Primary unpaid caregiverAny primary caregiver who provides care on a voluntary, uncompensated, regular, sustained basis.

Legal representativeGuardian or healthcare proxy who directly participates in the member's care.

Role requirementFamily representative must directly participate in the overall care of the member for CPT 96167 to be considered reasonable and necessary.

OpenPayer

Psychological evaluation and management of non-mental health disorders

Coverage Criteria

Coding

Provider Actions and Requirements

Background

Definitions

Level of Care Criteria

Treatment Modalities

Visit Limits and Billing Rules