CPT 96160
CPT code 96160 allows allergists to get reimbursed when they make use of certain standardized asthma assessment instruments. Specifically, CPT code 96160 describes the administration of patient-focused health risk assessment instruments with scoring and documentation, per standardized instrument. For example, the Asthma Control Test (ACT) helps allergists determine whether asthma is being properly controlled and is only valid when completed by the patient or parent.
CPT 96161
In contrast, CPT code 96161 describes the administration of caregiver-focused health risk assessment instruments for the benefit of the patient, with scoring and documentation, per standardized instrument. Allergists making use of standardized health assessments for asthma, such as a pediatric asthma control and communication instruments or asthma control tests, should consider whether it is appropriate to bill CPT Code 96160 or 96161 in the case of the caregiver.
CPT codes 96160 and 96161 are both categorized in the CPT code book under the umbrella of health behavior assessment and intervention services. This category of codes helps “identify and address the psychological, behavioral, emotional, cognitive, and interpersonal factors important to the assessment, treatment, or management of physical health problems.”
When using these codes, the “patient’s primary diagnosis is physical in nature and the focus of the assessment . . . is on factors complicating medical conditions and treatments.”
The health assessment instrument should be scorable and include the “evaluation of the patient’s responses to disease, illness or injury, outlook, coping strategies, motivation, and adherence to medical treatment” and is typically “conducted through health focused clinical interviews, observation, and clinical decision making.” Medicare directives further clarify that the focus of these codes “is not on mental health, but on the biopsychosocial factors important to physical health problems and treatments.”
Medicare has very specific documentation requirements that you’ll want to become familiar with and include in your patient notes.
Allergists should consult with the payer regarding its policy and payment amount before submitting a claim. For instance, Medicare payment for CPT codes 96160 and 96161 is very low – $2.77. Currently, no diagnosis code limitations apply for purposes of billing Medicare. Further, both CPT codes 96160 and 96161 may be used for telemedicine services rendered to Medicare beneficiaries.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
