96165
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.11
Facility
$4.01
Non-Facility
$5.01
Documentation Required
- 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.
Key Coverage Criteria
- 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.
4 Active Policies
A52434 — Health and Behavior Assessment/Intervention Medical Policy Article
J06
A56562 — Billing and Coding: Health and Behavior Assessment/Intervention
L37638 — Health and Behavior Assessment/Intervention
CIGNA-A004 — Preventive Care Services - (A004)
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.