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96127 CPT Code: Are You Maximizing Your Telehealth Billing?

The 96127 CPT Code has been getting serious attention from professionals who are looking to maximize their services / revenue with screening or assessment services. This specialized code has been approved by the Center for Medicare and Medicaid Services Administration (CMS) since 2015 (search for “92167” on page 14 of this CMS document). Fees associated with the 96127 code can be almost $25 per administration, and are billable up to four times per year. A variety of sources are now offering tools for behavioral health professionals to quickly and easily be implementing such a service, and billing automatically. One such service offered by an affiliate of TBHI is Mentegram, an automated practice management and patient engagement platform that offers clinicians a wide range of tools and services to expedite the routine communication needs of a practice to focus on patient-care.

Initially, the code description by the American Medical Association (AMA) and was then adopted by the Centers for Medicare and Medicaid Services (CMS) as the following: 96127 – Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument.

Aug 15.Volume 25, Issue 8, August 2015

Specific assessment tools acceptable for billing the 96127 CPT Code can most often include any one of the tests listed in the chart below. Although it is wise to contact any carrier to obtain prior approval for the specific instrument planned, the 96127 code can often be used to report a brief assessment for ADHD, depression, suicidal risk, anxiety, substance abuse, eating disorders, etc. It is of note that no professional involvement is required and administration, that is, scoring and documentation can be done by administrative staff.

Why was the 96127 CPT Code developed?

This code was created as part of the Affordable Care Act’s federal mandate to include mental health services as part of the essential benefits package that now must be included in all insurance plans. The mandate covers child and adult services such as depression screening, alcohol and drug screening, and brief behavioral assessments in children and adolescents.

The chart below is not definitive, but includes many of the common screening instruments that have successfully been billed under the 96127 code. Unlike many other psychological tests, the 96127 CPT Code  can be billed on the same date of service as other common services such as psychiatry or therapy appointments. It is also of note that it remains appropriate to include such instruments under the request for psychological testing (96101- 96102) if they are being used as part of a larger evaluation and test battery by the professional. Use of the 96127 CPT code is appropriate when a single or small number of screening instruments is being used, for example, as part of a standard clinical intake. Scoring and its documentation should be in the patient/client record, but the direct involvement is not necessarily required.

926127-cpt

Mentegram

TBHI accepted Mentegram into the TBHI affiliate network over a year ago.  As affiliates, we help each other’s services be more widely known to the behavioral health community. (We have been delighted to hear many of their satisfied customers tell us of their experiences as we watch them grow.) Using the Mentegram system, billing for the 96127 CPT Code can be as easy as using these steps to administer the screening or assessment instrument without the direct involvement of a professional, given how they incorporate the required tools in their suite of services:

  1. Assign the assessment to the patient through Mentegram
  2. Patient submits forms through tablet or computer
  3. Review results and generate report in Mentegram
  4. Attach as a lab report to the e-claim in your EHR

Can You Use the 96127 CPT Code?

Screening and assessment has to involve a “medical” provider, which is often too literally taken to mean that such tools must be administered  under an MD’s supervision, and/or that a MD needs to file the report. For example, a primary care physician or psychiatrist would need to be involved. However, practitioners who can bill for using this code can include other licensed professionals, such as psychologists, depending on state definitions. More specifically, some states recognize a wide variety of practitioners as “medical” providers. For instance, in California, psychologists can be considered medical providers for services delivered within the state. Professionals then, would do well to inquire about such definitions within their own state’s definitions of their scope of practice. This information can usually be found through their respective licensing boards, and often is available through a quick website search of the practice or business and professions codes.  

Conditions to be screened and assessed can include many of the conditions listed in  ICD-10 and DSM-V, as medically necessary. Situations that warrant medical necessity can involve a post hospitalization event, new diagnosis or complex medical issue, patients with pain, patients with substance abuse, and patients diagnosed with or being treated for mental illness.

96217 Resources:

Links

Other Materials

  • Distinguishing between screening and assessment for mental and behavioral health problems: A statement from an American Psychological Association Practice Organization work group on screening and psychological assessment. American Psychological Association Practice Organization. Washington, D.C. 

To learn about other ways to improve your bottom line with telemental health services, visit our Certificate training page for discounted course packages, and more specifically, our reimbursement course, Reimbursement Strategies Increasing Authorization & Payment.

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28 comments on “96127 CPT Code: Are You Maximizing Your Telehealth Billing?

  1. I think the “four times per year” is incorrect. You may be referring to the “up to four units per day” language, meaning if your patient completes PHQ-4, PHQ-9, and GAD-7 on same day, then one could bill 3 units of 96127.

    • Dr Daviss,

      You are absolutely correct. CPT Code 96127 can be billed four times for each patient visit, using four different assessment tools or instruments. Thank you for drawing my attention to this important issue. This billing code is good news for all of us who work in medical settings where many patients are regularly screened for a variety of issues. I appreciate your taking the time, and hope others feel free to comment on anything they want clarified.

  2. Can an Licensed Clinical Social Worker in private practice bill insurance companies/medicare for this code? I practice in Florida

  3. I find this confusing in the link you reference above Marlene. it looks like you can administer 4 screens per visit up to 4 times a year. Since the behavioral health field is moving towards measurement-based care using tools like the PHQ9 it would be nice if we could get paid for using the PHQ9 as much as once a month. i heard from a pediatrician in Delaware they could only bill and get paid for it 4 times a year. See the questions from the link below which seem to confirm up to 4 screens up to 4 times a year

    When can I bill for CPT 96127?

    CPT 96127 can be billed on the same date of service as other common services such as psychiatry or therapy appointments and is appropriate when used as part of a standard clinical intake. Primary care and other specialists may use CPT code 96127 when screening and assessing their patients, up to four times per year per patient.

    What mental health conditions does it cover?

    It should be used to report a brief assessment for ADHD, depression, suicidal risk, anxiety, somatic symptom disorder and substance abuse and can be billed every time it’s medically necessary, with a maximum of 4 different screens per visit, but this may vary based on insurance provider.

    • It helps to understand the purpose/goal of a code. The purpose of this code for primary care offices to do mental health screenings within their offices. Once a disorder is potentially identified, they can then refer out to specialists, like allied health professionals. This code is not to be used by mental health or substance use professionals (behavioral professionals) who want to conduct assessments in addition to their regular treatment services. If anyone out there has any more information to add, please comment.

    • Lori,

      Making sense of billing issues is challenging, indeed. A big part of the problem in the United States is that payors differ across states and across companies, so giving you a single clear answer isn’t possible. The code you mentioned should work for the screens described, but any given company may have other requirements. Get all your facts up front from the payors) that you are considering, then please come back here to let us know what you learned. (Yes, this can involve a fair amount of leg work.) The more we help each other the further we will get.

  4. We have a client that has a program in place to identify patients at risk for Opioid abuse an assessment testing is issued via a tablet and after completion receives a scoring identifying the risk level. Can we bill the assessment and scoring portion using 96127? Does it have to involve a physician or can it be administered to by the administrative staff?

    The results are provided to the physician for them to provide education/counselling to the patient which is then billed by the physicians office. (Pain Mgmt). Thank you!

    • J Vedder, While giving an answer may seem easy, anyone would need to know more about the payor. Medicare, Medicaid, private party, states, can all differ so there’s no way for an outsider to be able to answer and be sure you will be successful. Some of these groups also have special carve-out for opioid treatment. Your best bet is to call the payor, get the name of the person you have contacted, and ask them all the questions you can think of. Make sure you document the information and who gave it to you, date, time, etc. Check back with them if your program takes some time to launch, just to make sure that their requirements haven’t change.

    • J,

      Contact the payor and ask them how to bill. Payors differ across states and across companies. The code you mentioned should work, but they may have other requirements. Get all your facts up front from the payor, then please come back here to let us know what you learned!

  5. Does the patient have to fill out the questionnaire? I have a MD that has EHR and asks the questions to the patient. Can we still bill for the 96127.

    • The code should work, but it is always wise to call the insurance company, get the name and number of the person involved and get them to tell you exactly how they want you to bill. There often are other steps involved beyond just using an approved CPT billing code. Credentialing is a hurdle that might be involved.

  6. I’m a Psych Nurse Practitioner ( solo practice) providing in office and telepsych care . If I administer the PHQ-9 & GAD-7 on each follow up with my psych patients ( as an objective measure for effectiveness of treatment) can I bill with w 96127 along with E&M billing codes ? Can I use the code along with my my initial evaluation billing code?
    If I administer a MOCA on select patients would I use the 99483 or 96127 code? It’s not listed as an inclusion under the 96127 code explanation. Thank You.

    • Ellen,

      For your telehealth billing, use the same code as you would in-person, but us “95” as a modifier code and “02” as your POS code. We only specialize in telehealth billing and therefore cannot answer your question about how to bill for PHQ, GAD-7 or MOCA. Given the general confusion about how to bill for these tests when delivering in-person care, if you cannot readily find a written response, administer one or more of these quick tests and send a bill to the payor. The explanation of benefits will give you tangible feedback and a place to start with questions for that payor.

      If you’d like help from a billing service that we’ve found to assist with these matters, you may want to contact Coast-to-Coast. They specialize in behavioral and telebehavioral health billing.

  7. I am an LCSW in a clinic of many types of clinical psychologists. For years, we’ve been asking some clients to take the PHQ-9/GAD-7 intermittently at various times between appointments. Sometimes we give them paper versions to bring back and sometimes it’s done over email. We use this method to keep track of their symptomatology across time and use to to help inform our care.

    I’ve recently learned about this code, but am confused on whether I can bill the assessment and scoring portion using 96127 for these folks? I’m assuming I just need to call our insurers to get their perspective, but does anyone have any experience around this sort of question?

    • Janeil,

      Thank you for your question. I wish I had a definitive answer for whether or not a clinician using a PHQ-9 or GAD-7 can now be reimbursed using the telehealth code. I invite anyone reading this to let us know if they have tried, and also encourage you to come back to inform our community if you bill for it. As with most of telehealth, there’s nothing wrong with trying to get reimbursed when you have offered a legitimate service. Most of the time, practitioners are pleasantly surprised. They often get paid – or get more information about what to do to get paid the next time.

    • Charisma,

      Unfortunately, payment for reimbursable telehealth billing codes all too often depends on the payer and their policies. It is best to contact the payer directly, get the name and title of the person with whom you are speaking, and document the response. Then offer a session or two and bill for it. No matter what people tell you, you won’t know for sure until the payor actually pays you. The biggest mistake made by providers is to fail to bill. The second biggest mistake in telehealth billing is offering too many sessions before actually sending a bill to the payer. I hope this helps.

      • Good morning Marlene, thank you for the information listed above, you’re very informative regarding this specific code. Can you advise on the diagnosis needed to support cpt code 96127 for Psychology

      • Nicole,

        I wish I could advise you about the specifics ways to support CPT code 96127, but my focus is on telehealth exclusively. However, I can give you some general pointers. First, encourage you to type “CPT 96127” into your favorite search bar and read what seems relevant. Then consider the special circumstances of the person you wish to treat, consider which technology you wish to use if you hope to deliver treatment via technology, research the literature related to that technology for that diagnostic group, and apply/legal/ethical requirements.

        We at TBHI give you many tools to do that quickly and efficiently. Every licensed professional has to do their own specific research related to the diagnosis as well as the treatment setting, just as we do in regular in-person clinical practice setting.

        I hope this helps.
        Marlene

          • Philip,

            CPT code 96127 (Brief emotional/behavioral assessment) was approved for reimbursement by CMS in early 2015. It is reimbursed by major insurance companies, such as Aetna, Anthem, Cigna, Humana, United Healthcare, Medicare and others. However, whether you are successful in billing it for telehealth depends on your setting, your licensure, the technology that you use, and the modifier codes that you use. I’d suggest that you contact your payer and ask them if they will pay, and specifically under which circumstances. If you can, ask them to send you documentation related to payment of that code. many times, someone will tell you something on the phone, but you don’t get paid when you bill. The devil is in the details. Get the specific wording of their payment requirements. Then try 1 or 2 sessions and bill. See what you get back.

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