How to report behavioral health assessment
Mental health is extremely important. This “umbrella” specialty of medicine deals with the issues that directly impact how we think, feel, and cope with our lives. As a result of all the stressful events currently experienced by billions of people all over the world, the demand for quality mental health services will increase exponentially within the next several years. In fact, according to the US National Library of Medicine, more than half of all Americans will be diagnosed with at least one mental disorder at some point in their lives in the nearest future.
No matter if you are a psychiatrist or a primary care physician (PCP), you should expect to see an increasing number of patients concerned about their mental state. However, no treatment is possible without a proper evaluation of a patient’s clinical condition. For this purpose, in 2015 CMS introduced 96127, a distinctive CPT code that can be used to indicate a brief behavioral assessment (such as depression screening, suicide risk, anxiety assessment, ADHD assessment, and screening for eating disorders). This procedure code can be reported by MD practitioners, and it is covered by the majority of commercial insurance carriers, pursuant to a 2015 Affordable Care mandate. It is often reported when performed in the context of preventive medicine services but may also be appended when screening is performed with other evaluation and management (E/M) services. Please be advised that brief behavioral health assessment requires a strong medical necessity to be documented in the medical records and indicated on a claim. This procedure code may be considered incidental to a regular E/M procedure. Clinical staff (e.g. registered nurse) can administer and score the completed instrument while the mid-level provider or physician incorporates the interpretation component into the accompanying E/M service, according to the CMS.
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