L29186-LCD

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Local Coverage Determination (LCD) for Health and Behavior Assessment/Intervention (L29186)

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29186

LCD Title

Health and Behavior Assessment/Intervention

Contractor's Determination Number 96150

Primary Geographic Jurisdiction opens in new window Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/02/2009 Original Determination Ending Date

Revision Effective Date

Revision Ending Date

CMS National Coverage Policy N/A

Indications and Limitations of Coverage and/or Medical Necessity

Health and Behavior Assessment procedures are used to identify the psychological, behavioral, emotional, cognitive, and social factors important to the prevention, treatment, or management of physical health problems. The focus is not on mental health, but on the biopsychosocial factors important to physical health problems and treatments.

Health and Behavior Intervention procedures are used to modify the psychological, behavioral, emotional, cognitive and social factors identified as important to or directly affecting the patient’s physiological functioning, disease status, health, and well-being. The focus of the intervention is to improve the patient’s health and well- being utilizing cognitive, behavioral, social, and/or psychophysiological procedures designed to ameliorate specific disease-related problems.

Indications:

Medicare will consider the Health and Behavior Assessment/reassessment procedures reasonable and necessary for the patient:

• Who has an underlying physical illness or injury, and

• For whom the purpose of the assessment/reassessment is not for the diagnosis or treatment of mental illness, and

• For whom there is reason to believe that a biopsychosocial factor may be significantly affecting the treatment, or medical management of an illness or an injury, and

• Who is expected to have the capacity to understand or respond meaningfully to the psychological intervention, and

• For whom there is a documented need for psychological support in order to successfully manage his/her physical illness and activities of daily living, and

• For whom the assessment/reassessment is not duplicative of other provider assessments

In addition, Health and Behavior Reassessment is considered reasonable and necessary for the patient:

• For whom there is a question of a sufficient change in psychological or medical status warranting re-evaluation of his or her capacity to understand or to respond meaningfully to the psychological intervention, and

Health and Behavior Intervention is considered reasonable and necessary for the patient:

• Who has an underlying physical illness or injury, and

• For whom the purpose of the intervention is not the treatment of mental illness, and

• Who are expected to have the capacity to understand or respond meaningfully to the psychological intervention, and

• Who require psychological intervention to address:

o Non-compliance with the medical treatment plan, or

o The biopsychosocial factors associated with a newly diagnosed physical illness, or an exacerbation of an established physical illness, when such factors affect symptom management and expression, health promoting behaviors, behaviors which place the patient or others at risk for safety, health-related risk-taking behaviors, and overall adjustment to medical illness, and

• For whom the specific psychological intervention (s) and patient outcome goal (s) have been clearly identified

Health and Behavior Intervention (with the family and patient present) is considered reasonable and necessary for patient and family representative*:

o When the family representative* directly participates in the care of the patient, and

o The psychological intervention with the patient and family is necessary to address biopsychosocial factors that affect compliance with the plan of care, symptom management, health-promoting behaviors, behaviors which place the patient or others at risk for safety, health-related risk-taking behaviors, and overall adjustment to medical illness.

*Family representative is identified as one of the following:

o Immediate family members (husband, wife, domestic partner, siblings, children, grandchildren, grandparents, mother, father),

o Primary caregiver who provides care on a voluntary, uncompensated, regular, sustained basis, or o Guardian or health care proxy

Limitations:

1. Health and Behavioral Assessment or Intervention are not considered reasonable and necessary to:

a. Update or educate the family about the patient’s condition

b. Educate non-immediate family members, non-primary care-givers, non-guardians, the non-health care proxy, and other members of the treatment team, e.g., health aides, nurses, physical or occupational therapists, home health aides, personal care attendants and co-workers about the patient’s care plan.

c. Treatment-planning with staff

d. Mediate between family members or provide family psychotherapy

e. Educate diabetic patients and diabetic patients’ family members

f. Deliver Medical Nutrition Therapy

g. Maintain the patient’s or family’s existing health and overall well-being

h. Provision of support services, not requiring the skills of a Clinical Psychologist (CP).

i. Provide personal, social, recreational, and general support services. These services may be valuable adjuncts to care; however, they are not psychological interventions. Examples of these services are:

§ Stress management for support staff

§ Replacement for expected nursing home staff functions

§ Recreational services, including dance, play, or art

§ Music appreciation and relaxation

§ Craft skill training

§ Cooking classes

§ Comfort care services

§ Individual social activities

§ Teaching social interaction skills

§ Socialization in a group setting

§ Retraining cognition due to dementia

§ General conversation

§ Services directed toward making a more dynamic personality

§ Consciousness raising

§ Vocational or religious advice

§ General educational activities

§ Tobacco withdrawal support

§ Caffeine withdrawal support

§ Visits for loneliness relief

§ Sensory stimulation

§ Games, including bingo games

§ Projects, including shopping outings, even when used to reduce a dysphoric state

§ Teaching grooming skills

§ Grooming services

§ Monitoring activities of daily living

§ Teaching the patient simple self-care

§ Teaching the patient to follow simple directives

§ Wheeling the patient around the facility

§ Orienting the patient to name, date, and place

§ Exercise programs, even when designed to reduce a dysphoric state

§ Memory enhancement training

§ Weight loss management

§ Case management services including but not limited to planning activities of daily living, arranging care or excursions, or resolving insurance problems

§ Activities principally for diversion

§ Planning for milieu modifications

§ Contributions to patient care plans

§ Maintenance of behavioral logs

Health and Behavior Assessment/Intervention services may only be performed by a clinical psychologist.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes

HEALTH AND BEHAVIOR ASSESSMENT (EG, HEALTH-FOCUSED CLINICAL INTERVIEW, BEHAVIORAL 96150 OBSERVATIONS, PSYCHOPHYSIOLOGICAL MONITORING, HEALTH-ORIENTED QUESTIONNAIRES), EACH

15 MINUTES FACE-TO-FACE WITH THE PATIENT; INITIAL ASSESSMENT

HEALTH AND BEHAVIOR ASSESSMENT (EG, HEALTH-FOCUSED CLINICAL INTERVIEW, BEHAVIORAL 96151 OBSERVATIONS, PSYCHOPHYSIOLOGICAL MONITORING, HEALTH-ORIENTED QUESTIONNAIRES), EACH

15 MINUTES FACE-TO-FACE WITH THE PATIENT; RE-ASSESSMENT

96152 HEALTH AND BEHAVIOR INTERVENTION, EACH 15 MINUTES, FACE-TO-FACE; INDIVIDUAL

96153 HEALTH AND BEHAVIOR INTERVENTION, EACH 15 MINUTES, FACE-TO-FACE; GROUP (2 OR MORE PATIENTS)

96154 HEALTH AND BEHAVIOR INTERVENTION, EACH 15 MINUTES, FACE-TO-FACE; FAMILY (WITH THE PATIENT PRESENT)

ICD-9 Codes that Support Medical Necessity XX000 Not Applicable

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

1. Because of the impact on the medical management of the patient’s disease, documentation must show evidence of coordination of care with the patient’s primary medical care provider or medical provider responsible for the medical management of the physical illness that the psychological assessment/intervention was meant to address.

2. Evidence of a referral to the Clinical Psychologist by the medical provider responsible for the medical management of the patient’s physical illness must be documented in the medical record for the initial assessment and for reassessment.

3. Documentation in the medical record by the Clinical Psychologist (CP) must include:

a. For the initial assessment, evidence to support that the assessment is reasonable and necessary, and must include at a minimum the following elements:

o Onset and history of initial diagnosis of physical illness, and o Clear rationale for why assessment is required, and

o Assessment outcome including mental status and ability to understand or respond meaningfully, and o Goals and expected duration of specific psychological intervention(s), if recommended.

b. For re-assessment, evidence to support that the re-assessment is reasonable and necessary must be documented in detailed progress notes. These detailed progress notes must include the following elements:

o Date of change in mental or physical status

o Clear rationale for why re-assessment is required

o Clear indication of the precipitating event that necessitates re-assessment, and o Changes in goals, duration and/or frequency and duration of services

c. For the intervention service, evidence to support that the intervention is reasonable and necessary must include, at a minimum, the following elements:

o Evidence that the patient has the capacity to understand and to respond meaningfully, and o Clearly defined psychological intervention planned, and

o The goals of the psychological intervention should be stated clearly

o There should be documentation that the psychological intervention is expected to improve compliance with the medical treatment plan, and

o Rationale for frequency and duration of services

ICD-9-CM diagnosis code(s) reflecting the physical condition(s) being treated must be present on the claim as the primary diagnosis.

Documentation to support that the indications of coverage have been met

For all claims, time duration (stated in minutes) spent in the health and behavioral assessment or intervention encounter should be documented in the medical record, and the quantity billed should reflect 1 unit for each 15 minutes (e.g., one hour equals 4 units of service).

Medical records need not be submitted with the claim; however, the medical record, (e.g., nursing home record, doctor’s orders, progress notes, office records, and nursing notes), must be available to the Carrier upon request.

Appendices

Utilization Guidelines § The initial assessment is limited to a maximum of one hour (4 units) per episode of care.

§ A reassessment is limited to a maximum of 15 minutes (1 unit) per day.

§ The intervention is limited to a maximum of 30 minutes (2 units) per day.

Sources of Information and Basis for Decision

Other Carriers’ policies (National Heritage Insurance Company) and (Trailblazers).

Casciani, J.M. (2003). Advancing the physical well-being of older adults: Mental health and primary care. Vericare Monograph 2.

Clarke, W.L., Cox, D.J., & et.al. (1997). The relationship between nonroutine use of insulin, food, and exercise and the occurrence of hypoglycemia in adults with IDDM and varying degrees of hypoglycemic awareness and metabolic control. The Diabetes Educator. (23) 1.

Friedman, R., Sobel, D. & et.al. (1995). Behavioral medicine, clinical health psychology, and cost offset. Health Psychology. (14) 6, 509-518.

Johnston, M. & Vogele, C. (1993). Benefits of psychological preparation for surgery: a meta -analysis. Annals Behavior Medicine, 15 (4): 245-256.

Advisory Committee Meeting Notes

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 12/04/2008

Revision History Number Original

Revision History Explanation Revision Number:Original Start Date of Comment Period:N/A

Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29186) replaces LCD L22471 as the policy in notice. This document (L29186) is effective on 02/02/2009.

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

96150 descriptor was changed in Group 1 96151 descriptor was changed in Group 1 96152 descriptor was changed in Group 1 96153 descriptor was changed in Group 1 96154 descriptor was changed in Group 1

Reason for Change