96164 – Behavioral Health Assessment / Diagnostic Service
CPT code 96164 represents a distinct mental or behavioral health service, including evaluation, therapy, or care coordination.
What is CPT
96164
?
96164 is a CPT code utilized for specific diagnostic services related to psychological assessments and testing. This entry provides a comprehensive overview of its clinical applications, necessary documentation, and considerations for reimbursement. Clinicians and providers are encouraged to ensure that their clinical notes are consistent with evidence-based practices, documenting treatment objectives, interventions employed, and the measurable progress of the patient. In instances where the billing of this code is based on time, it is critical to accurately record the start and stop times to substantiate the duration billed.
Documentation Tips
When billing for services that are time-based under this code, it is essential to document both the start and stop times of the session. Additionally, provide detailed notes that include the specific therapeutic modality or assessment tool utilized, the clinical focus of the session, the patient’s responses, and a clear plan for follow-up care. For assessments involving scored instruments, retain copies of all completed tools to facilitate verification of the assessment process. In cases of telehealth services, ensure that consent is documented along with details about the technology platform used for the session. Employing consistent documentation structures, such as SOAP (Subjective, Objective, Assessment, Plan) or DAP (Data, Assessment, Plan), is recommended to maintain audit readiness and enhance the quality of documentation.
At a Glance
- Service Type: Psychological Assessment
- Use Case: Diagnostic Testing
- Typical Setting: Outpatient clinics, telehealth, or as permitted by payer policies
- Billing Unit: Per session or per assessment tool (varying based on specific code usage)
- Common Pairings: 90791, 96127, psychotherapy-related codes
Billing Examples
For instance, a clinician may administer the Patient Health Questionnaire-9 (PHQ-9) to evaluate a patient’s depressive symptoms. Upon completion, the scored instrument is documented and billed accordingly. Furthermore, clinicians may conduct comprehensive neuropsychological assessments that involve various standardized tests. These assessments would follow a structured workflow that includes administration, scoring, and interpretation, which would justify the use of this assessment code. Each of these examples highlights the importance of thorough documentation supporting the clinical rationale behind the services billed.
Compliance Guidelines
- Before billing, verify payer-specific coverage and authorization requirements to ensure compliance.
- Document the medical necessity of services provided, linking them clearly to appropriate ICD-10 diagnoses.
- Utilize the correct modifiers when necessary, such as modifier 95 for telehealth services, to ensure proper claims processing.
- Avoid upcoding by selecting the code that accurately reflects the time spent and the complexity of the services rendered.
- Regularly conduct audits to identify potential areas of improvement in documentation and to reduce the likelihood of claim denials.
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 purpose of CPT code 96164?
A: CPT code 96164 is designated for psychological assessment services that align with the definition of the code. It is important to ensure that documentation clearly supports the services billed under this code.
Q2: Is it permissible to bill this code for telehealth services?
A: Yes, many payers allow billing for telehealth services under this code, provided that the service is delivered synchronously and all necessary modifiers and patient consent are documented as per payer policies.
Q3: What specific documentation might payers request for audit purposes?
A: Payers typically require documentation that includes the time spent on the assessment, the therapeutic techniques or instruments used, the patient’s response to the interventions, and a clear connection to a covered ICD-10 diagnosis.
Q4: Can CPT 96164 be billed in conjunction with other services?
A: Yes, when billing for multiple services, it is essential to document the distinct time spent on each service and provide a rationale for each billed code. Utilize add-on codes or follow E/M (Evaluation and Management) separation rules where applicable.
Q5: What are some common reasons for claim denials related to this code?
A: Common denial reasons include inadequate documentation of time spent, failure to demonstrate medical necessity, incorrect use of modifiers, or billing that exceeds the allowed frequency for the service.
