Health Policy Corner: Health and Behavior Codes

Antonio E. Puente

Antonio E. Puente

Antonio E. Puente, PhD
University of North Carolina Wilmington
(Puente@uncw.edu)

In 1966, the American Medical Association developed a coding system known as Current Procedural Terminology (CPT) to describe professional health services. Today, CPT consists of approximately 8,000 codes that are used by approximately 130 different qualified health providers to document and bill for their services. Each code has a specific five-digit number and description as well as a reimbursable value. Services captured by these codes must be professional health services provided across the country by “Physicians” or “Qualified Health Professionals.” Clinical efficacy is established and documented in peer-reviewed scientific/professional literature (preferably from the US).

New CPT codes are proposed by the healthcare specialties, often in collaboration with other healthcare organizations. The codes are then presented to the 17-member CPT Editorial Panel, which includes representatives from the Centers for Medicare & Medicaid Services (CMS), the Blue Cross and Blue Shield Association, and other stakeholders. If the panel accepts the codes then they are studied at the Relative Value Committee (RUC) to determine their value.

I have represented the American Psychological Association since the AMA granted representation on the CPT Advisory Committee to non-physicians in 1992. I held that position for 15 years when I was nominated and elected to the CPT Editorial Panel itself.

Health related expenditures comprise approximately 17% of the Gross Domestic Product and are increasing at an alarming rate. The 8,000 procedures previously mentioned further subdivide the portion of the 17% that is associated with physician or other qualified health provider expenses. As these numbers continue growing exponentially, there is increasing need to reduce this expenditure. One approach to control this has been the recent introduction of the Affordable Care Act (ACA). The ACA places great emphasis on integrative care and behavioral approaches to reduce health care costs. The approach to engage psychologists with the larger health system involves the application of both assessment and intervention strategies embedded with traditional medical and emerging health care practices.

The idea of the application of behavioral strategies interacting with health is the foundation for the establishment of Division 38, the specialty of health psychology, and robust science interfacing psychology and health. However, the reality is that without economic support to pursue this critical interface, the growth of health psychology would not be realized or, worse yet, there would be no such specialty.

The Interdivisional Healthcare Caucus, headed by APA staff member Randy Phelps, PhD, proposed in the late 1990s that codes that would support such integrative activities should be developed. About that time, this author (who was representing APA as an advisor to the panel) was on a small task force to update the CPT system. I had requested access to CPT Evaluation and Management (E & M) codes, which are not only the standard for case management in medicine, but limited to those considered “physicians” by the federal government. Though APA had two opportunities to become “physicians” according to Medicare (1965 and 1989), the organization’s leadership chose to do otherwise. In all likelihood, the APA leadership did not understand the importance of being included in Medicare, nor the fact that there are only two levels of providers, physicians and technicians. By opting out, psychologists were effectively placed in the category of technician. The best we have been able to do is for CMS to allow for “mental work” in the codes that we use and, of course, the Health and Behavior (H & B) codes.

The alternative to gaining access to the E & M codes became the foundation for the H & B codes. In essence, these codes are the case management codes for psychology as they apply to health care. There is a critical difference between these and other codes used by psychologists (for more information, visit www.psychologycoding.com). The primary focus of the H & B codes is for non-psychiatric illness (i.e., acute or chronic physical health illness), and thus they require a medical diagnosis. Both assessment and intervention codes are included.

The assessment codes are as follows:

  • 96150
    • Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires)
    • Each unit = 15 minutes
    • Face-to-face with the patient
    • Initial assessment
  • 96151
    • Re-assessment
    • Each unit = 15 minutes
    • Face-to-face with the patient

The codes could involve identification of psychological, behavioral, emotional, cognitive and/or social factors in the prevention, treatment and/or management of physical health problems. The focus is on biopsychosocial and not mental health factors. Specific activities that can be done under the aegis of these codes would be:

  • Health-focused clinical interview
  • Behavioral observations
  • Psychophysiological monitoring
  • Health-oriented questionnaires

The intervention codes are as follows:

  • 96152
    • Health and behavior intervention
    • 1 unit = 15 minutes
    • Face-to-face
    • Individual
  • 96153
    • Group (2 or more patients, usually 6-10 members)
  • 96154
    • Family (with the patient present)
  • 96155
    • Family (without the patient present; not being reimbursed)

In essence, the purpose of these codes are for modification of psychological, behavioral, emotional, cognitive and/or social factors affecting physiological functioning, disease status, health and/or well-being. The focus of the intervention is the improvement of health with cognitive, behavioral, social and/or psychophysiological procedures. The interventions could be cognitive, behavioral, social, or psychophysiological in nature.The time allowed able for these codes varies according to carrier. In general these are reasonable estimates of allowable time.

  • Initial Assessment = 4 – 8 units
  • Re-assessment      = 4 – 6 units
  • Group                   = 8 units
  • Intervention         = 24 to 48 units/day

Of interest with these codes is that if a patient requires a psychiatric service (e.g., 90791) and a health and behavior service, the predominant service should be reported. In no case should both sets of services be reported on the same day. In the past, patients could not have “been diagnosed with mental illness.” However, it is now appreciated that both physical and mental diagnoses can be present simultaneously. If service is not completed in one day, then the date of service coded should be the one in which the service was finalized.The major issue facing psychology is probably philosophical. Some want to continue being attached primarily or possibly only to mental health issues. The idea of working on “medical” issues is considered by some as outside of psychology’s scope of practice. For others, especially health psychologists, this is the furthest thing from their mission and scope of practice. A problem exists, however, even within this community in the infrequent use of these codes. Whether this is due to misunderstanding of these codes or to their reimbursement is not known. What is known is that APA (with the help of Randy Phelps and Neil Pliskin) have placed these codes on the CPT agenda for reconsideration. It is time not only that these codes be brought up to speed with the current practice of health psychology but that health psychologists (and others) seize the opportunity to impact all of health care, not just mental health.

Editor’s note: Dr. Puente was recently elected President-elect of the American Psychological Association. He will assume the role of APA President in 2017. Congratulations, Dr. Puente!