CODING & DOCUMENTATION
Fam Pract Manag. 2020 May-June;27(3):31.
Author disclosure: no relevant financial affiliations disclosed.
- MENTAL HEALTH SCREENINGS
- REPORTING MULTIPLE MANAGEMENT SERVICES
- TRANSFERRING PAPER NOTES TO THE MEDICAL RECORD
MENTAL HEALTH SCREENINGS
I administered both the PHQ-9 (screening for depression) and the GAD-7 (screening for anxiety) to a patient with a commercial health plan. What codes should I report?
You should report CPT code 96127, “Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument,” with one unit for each screening instrument completed, and be sure to document the instruments used and the scores obtained. Health plans using Medicare's National Correct Coding Initiative (NCCI) Medically Unlikely Edits will typically allow reporting of two units on the same date of service without a modifier, but distinct diagnosis codes should be linked to each service line.
Use screening diagnosis codes only if the assessment was purely preventive and not prompted by any signs or symptoms. For instance, use ICD-10 code Z13.31, “Encounter for screening for depression,” when screening for depression in patients at least 12 years old without reported symptoms. This is a preventive service defined under the Affordable Care Act and covered by many health plans. On the other hand, if the assessment was given because the patient was showing signs of depression, you should use a diagnosis code that fits those symptoms, such as R45.3, “Demoralization and apathy,” or R45.851, “Suicidal ideation.”
ICD-10 code Z13.39, “Encounter for screening examination for other mental health and behavioral disorders,” can be reported with CPT code 96127 when anxiety assessments are given to asymptomatic patients. But this is not currently a recommended preventive service and therefore may not be covered.
For patients showing signs of anxiety, a diagnosis code related to the symptoms should be reported instead, such as ICD-10 code R45.82, “Worries.”
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Send questions and comments to email@example.com, or add your comments below. While this department attempts to provide accurate information, some payers may not accept the advice given. Refer to the current CPT and ICD-10 coding manuals and payer policies.
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