96137 – Behavioral Health Assessment / Diagnostic Service
CPT code 96137 represents a distinct mental or behavioral health service, including evaluation, therapy, or care coordination.
What is CPT
96137
?
96137 is a CPT code designated for the administration of standardized assessment instruments in the behavioral health field. This code is essential for clinicians conducting diagnostic evaluations and in-depth assessments, as it facilitates the accurate billing for time spent administering these tools. The following entry provides a comprehensive overview of the clinical purpose of this code, outlines documentation expectations, and discusses payer considerations. It is imperative for providers to ensure that their clinical notes reflect evidence-based interventions, clearly outlining treatment goals, specific interventions employed, and measurable progress observed. When billing for services under this time-based code, it is crucial to document the precise start and stop times to substantiate the duration of the billed service.
Documentation Tips
To ensure compliance and facilitate accurate reimbursement, it is essential to document start and stop times when billing for time-based assessments. Additionally, clinicians should include the specific therapeutic modality or assessment instrument utilized, the clinical focus of the session, the patient’s response, and a detailed plan for follow-up care. For scored instruments, keep copies of the completed assessment tools in the patient’s file. If the service is conducted via telehealth, it is important to document the patient's consent as well as the telehealth platform used. Adopting consistent documentation structures, such as SOAP (Subjective, Objective, Assessment, Plan) or DAP (Data, Assessment, Plan), can enhance audit readiness and ensure that all necessary information is easily accessible during compliance reviews.
At a Glance
- Service Type: Assessment
- Use Case: Diagnostic / Testing
- Typical Setting: Outpatient clinic, telehealth, or other approved settings per payer policy
- Billing Unit: Billed per session or per instrument, depending on specific coding guidelines
- Common Pairings: 90791, 96127, psychotherapy codes
Billing Examples
An example of utilizing CPT code 96137 would be when a clinician administers the Patient Health Questionnaire-9 (PHQ-9) to evaluate a patient for depressive symptoms. The clinician would score the instrument, document the findings in the patient's record, and then bill the service under code 96137. In another scenario, a psychologist may perform a comprehensive neuropsychological evaluation, which includes the administration, scoring, and interpretation of various standardized tests. This thorough approach justifies the use of assessment codes, as it demonstrates the clinical need for the testing and the time invested in the patient's care.
Compliance Guidelines
- Before billing, verify payer coverage and authorization requirements to ensure compliance with specific guidelines.
- Document medical necessity for the assessment and ensure that all services are linked to appropriate ICD-10 diagnoses.
- Utilize correct modifiers as required, for instance, modifier 95 for telehealth services, to indicate that the service was delivered remotely.
- Avoid upcoding; select the code that accurately reflects the documented time spent and the level of service provided.
- Conduct regular audits of billing practices to minimize claim denials and enhance the quality of documentation, ensuring that it meets payer standards.
Common ICD-10 Codes
Helpful links for mental health billing and documentation
- F32.9: Major depressive disorder, single episode, unspecified
- F41.1: Generalized anxiety disorder
- R45.0: Nervousness
- Z13.89: Encounter for screening for other disorders
- F90.0: Attention-deficit hyperactivity disorder, predominately inattentive presentation
Additional Resources
Helpful links for mental health billing and documentation
Related CPT Codes
Helpful links for mental health billing and documentation
Got questions? We’ve got answers.
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Q1: What clinical activities align with this code?
A: CPT code 96137 is applicable when the clinician engages in standardized assessment activities as defined by the code; it is vital that documentation substantiates the billed service.
Q2: Is it permissible to bill this code through telehealth?
A: Yes, many payers allow billing for telehealth services using this code, provided that the service is synchronous and all required modifiers and patient consents are properly documented. Always consult payer policies for specific guidelines.
Q3: What specific documentation may payers request for this code?
A: Payers typically request documentation that includes the time spent on the assessment, the therapeutic techniques or instruments utilized, the patient’s responses during the evaluation, and a clear connection to a covered ICD-10 diagnosis.
Q4: Can this code be billed in conjunction with other services?
A: When billing multiple services, it is important to document distinct time allocations and provide a rationale for each billed service. Utilize add-on codes or E/M separation rules where applicable to support accurate billing.
Q5: What are common reasons for claim denials associated with this code?
A: Common denial reasons include incomplete time records, insufficient documentation of medical necessity, incorrect use of modifiers, or billing that exceeds frequency limits established by payers.
