Does 96158 require prior authorization?

No, 96158 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 96158?

Medicare facility rate: $59.79. Non-facility rate: $73.82. Work RVU: 1.66.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

1.66

Facility

$59.79

Non-Facility

$73.82

Medical record must contain documentation supporting medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Each claim must be submitted with ICD-10-CM diagnosis code(s) that describe the patient's condition and reasons for the service; claims without a valid ICD-10-CM code will be returned as incomplete.
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
If initial assessment or reassessment is completed over multiple encounters, the date of service should be the date the interview was finalized on the claim.

Patient has an underlying physical illness or injury for which the HBAI service is intended.
There is documentation that biopsychosocial factors are significantly affecting treatment or medical management of the illness or injury.
Patient is alert, oriented, and has capacity to understand and respond meaningfully during a face-to-face encounter.
There is a documented need for psychological evaluation or intervention to successfully manage the patient's physical illness and activities of daily living.
The HBAI assessment is not duplicative of other provider assessments.
Reassessment is reasonable only when documentation shows a sufficient change in mental or medical status warranting re-evaluation of the patient's capacity to understand and cooperate with medical interventions.

A52434 — Health and Behavior Assessment/Intervention Medical Policy Article

J06

AETNA-CPB-0511 — Eating Disorders

A56562 — Billing and Coding: Health and Behavior Assessment/Intervention

L37638 — Health and Behavior Assessment/Intervention

CIGNA-A004 — Preventive Care Services - (A004)

Ask Verity about documentation requirements, denial risks, or coverage in your state.