96138 – Behavioral Health Assessment / Diagnostic Service
CPT code 96138 represents a distinct mental or behavioral health service, including evaluation, therapy, or care coordination.
What is CPT
96138
?
96138 is a CPT code utilized for various assessment services, specifically pertaining to diagnostic testing and evaluation of mental health conditions. This entry provides a comprehensive overview of the clinical purpose of this code, documentation expectations, and considerations for payer requirements. It is essential for providers to ensure that clinical notes are aligned with evidence-based interventions. This includes a thorough recording of treatment goals, interventions employed, and measurable progress indicators. When billing for services associated with this code, particularly those that are time-based, it is crucial to document the start and stop times accurately to substantiate the billed duration.
Documentation Tips
When billing for time-based psychotherapy under CPT code 96138, it is vital to document both the start and stop times of the session. Additionally, practitioners should include information about the therapeutic modality employed or the specific assessment instrument utilized, the clinical focus of the session, patient responses to interventions, and a clearly defined plan for follow-up care. For assessments using scored instruments, it is advisable to retain copies of the completed tools for auditing purposes. In the case of telehealth services, ensure that documentation includes details of patient consent and the technology platform used. To maintain audit readiness, utilizing a consistent documentation structure such as SOAP (Subjective, Objective, Assessment, Plan) or DAP (Data, Assessment, Plan) is recommended.
At a Glance
- Service Type: Assessment
- Use Case: Diagnostic and Testing
- Typical Setting: Outpatient clinic or telehealth (as per payer policies)
- Billing Unit: Per session or per instrument (varies based on specific code)
- Common Pairings: 90791, 96127, psychotherapy codes
Billing Examples
For instance, a clinician may administer the PHQ-9, a standardized instrument designed to assess depressive symptoms in a patient, ensuring that the scored results are recorded and billed appropriately under CPT code 96138. In another scenario, a clinician may conduct a series of neuropsychological tests that involve administration, scoring, and interpretation, all of which fall within the workflows justifying the use of this assessment code. This code can also be employed when a clinician evaluates a patient’s cognitive function using a tool such as the Montreal Cognitive Assessment (MoCA), documenting the results and relevance to treatment planning.
Compliance Guidelines
- Always verify payer coverage and authorization requirements prior to billing for services using this code.
- Document medical necessity clearly and ensure that all services rendered are linked to appropriate ICD-10 diagnoses.
- Use the correct modifiers, such as modifier 95 for telehealth services, as required by specific payers.
- Avoid upcoding; select the most accurate code that corresponds to the documented time spent and level of service provided.
- Conduct regular audits of billing practices to minimize claim denials and enhance the quality of documentation.
Common ICD-10 Codes
Helpful links for mental health billing and documentation
- F32.9
- F41.1
- R45.0
- Z13.89
- F90.0
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 is the primary use of this code?
A: CPT code 96138 is designated for clinical activities that align with assessment and testing services in mental health care. It is crucial that documentation substantiates the services billed under this code.
Q2: Is it permissible to bill this code for telehealth services?
A: Yes, many insurance payers allow the billing of this code via telehealth, provided the service is delivered synchronously and all necessary modifiers and patient consent documentation are in order. Always verify specific payer policies regarding telehealth coverage.
Q3: What type of documentation might payers request for this service?
A: Payers may request detailed documentation that includes the time spent on the service, the therapeutic techniques or assessment instruments utilized, patient responses during the session, and a clear linkage to a covered ICD-10 diagnosis.
Q4: Can CPT code 96138 be billed in conjunction with other services?
A: Yes, when billing for multiple services, it is essential to document distinct timeframes and rationales for each. Utilize add-on codes or adhere to Evaluation and Management (E/M) separation rules when applicable.
Q5: What are some common reasons for claim denials related to this code?
A: Common denial reasons include insufficient documentation of time records, lack of medical necessity, incorrect use of modifiers, or billing that exceeds established frequency limits set by payers.
