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Social Worker

Kristene Posted Wed 18th of July, 2012 21:29:22 PM

Are there any codes that are available to be billed out by a Social Worker who provides face to face services to a patient to assess their needs and manage the patient directly or find other resources available?

SuperCoder Answered Fri 20th of July, 2012 00:39:41 AM

Coding Guidelines
1. CPT codes 96150 - 96154 represent services offered to beneficiary who present with
established illness or symptoms, the purpose of the assessment is not for the diagnosis or
treatment of mental illness, and may benefit for evaluations that focus on the
biopsychosocial factor related to the beneficiary’s physical health status
2. Physician’s must bill health and behavior assessment and/or intervention services with an
Evaluation and Management or preventive Medicine service codes.
3. Medical records must document the specific underlying medical problem
4. Health and behavior assessment normally will be performed in an office or facility
setting.
5. Health and behavior assessment codes may not be used for physician (example: medical
doctor, nurse practitioner, physician assistant, clinical nurse practitioner) or clinical social
worker services.
6. CPT codes 96150 – 96154 are to be billed as one service for each 15 minute of face-toface contact with the beneficiary(s).
*7. When more than four CPT codes 96150 are submitted by a provider/group the additional
services will be denied. If a redetermination is requested, documentation showing the
medical necessity of the additional time must be submitted.

CPT Codes
96150 Health and behavior assessment (eg, health-focused clinical interview, behavioral
observations, psychophysiological monitoring, health-oriented questionnaires),
each 15 minutes face-to-face with the patient; initial assessment

96151 Health and behavior assessment (eg, health-focused clinical interview, behavioral
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)

Diagnoses that Support Medical Necessity
Medical diagnoses only
Reasons for Denial
1. Beneficiaries who do not have specific underlining medical condition.
2. Services for preventive medicine counseling and/or risk factor reduction intervention.
3. Services to beneficiaries who require psychiatric services (services should be billed with
CPT codes 90801 – 90899).
4. Evaluation and Management services, including Preventive Medicine, Individual
Counseling codes 99401 – 99404, and Preventive Medicine, Group Counseling codes
99411 – 99412 billed on the same day as 96150 – 96154. 5. Health and behavior assessment and/or intervention performed by a physician, clinical
nurse specialist, nurse practitioner, physician assistant. These services should be billed
using the appropriate evaluation and management CPT codes.
6. Health and behavior assessment and/or intervention performed by a clinical social
worker. Per CFR Title 42, Part 410.73(b)(1) the services of a clinical social worker are
limited to the diagnosis and treatment of mental illness.
7. Health and behavior assessment and/or intervention performed by physical therapist, or
occupational therapist.
8. Smoking cessation; (use CPT codes G0375 - G0376).
Additional information may be found at
http://www.cms.hhs.gov/manuals/14_car/3b5111.asp#_1_5 define SW ect
http://www.cms.hhs.gov/manuals/pm_trans/R1660B3.pdf

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