Risk Assessment CodesStarting January 1, 2017, medical coding companies began using new codes to report administration and scoring of a patient-centered health risk assessment and a caregiver-focused health risk assessment.

Health risk assessment tools evaluate a person’s risk of developing a disease. Primary care physicians (PCPs) routinely use these tools which have the potential to prevent chronic disease. Based on the results of the assessment, the physician conducting the assessment can take action, such as referral to a specialty provider or community resource. Starting January 1, 2017, medical coding companies began using new codes to report administration and scoring of a patient-centered health risk assessment and a caregiver-focused health risk assessment. It is necessary to appropriately report the code for the specific screen or assessment performed.

The CPT codes for health risk assessment/screening that are in use during 2017 are:

96110 Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument

96127 Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument

New in 2017

96160 Administration of patient-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation, per standardized instrument.

Code 96160 replaced deleted code 99420 (administration and interpretation of health risk assessment instrument, e.g., health hazard appraisal).

96161 Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument

96161 should be reported for use of a standardized instrument to screen for health risks in the caregiver for the benefit of the patient. 96161 is to be reported to the patient’s health plan as it is a service for the benefit of the patient.

Further Clarifications on the Use of 96160 and 96161

In an article published in May 2017, AAP provided further clarity about the use of 96160 and 96161:

  • When to report 96160 and 96161:
    • Practice expense is incurred to administer the instrument (such as nurse time or for purchase of the screen).
    • The instrument is standardized.
    • The instrument is scorable.
    • The results are documented in the medical record.
  • Meaning of the term “standardized”: CPT defines “standardized” in an article as “previously validated tests that are administered and scored in a consistent or ‘standard’ manner”.
  • What “scoring” constitutes: This term distinguishes between a true health risk assessment and history gathering forms. At minimum, the instrument has to provide a threshold result or pertinent yes/no responses that would indicate a patient’s risk for an adverse health outcome or risk for further exacerbation of a current, typically chronic, medical condition.
  • Billing: Codes 96160 and 96161 are billable with the following primary codes:
    • Outpatient evaluation and management (E/M) service codes 99201-99215
    • Preventive medicine service codes 99381-99395
    • Codes 96127 and 96110 which are applied per standardized instrument when screening for emotional/behavioral and developmental status respectively (as long as the instruments are unique)
    • Many other E/M services
      AAP states that payment is retroactive to January 1.
  • Use of coding edits: One issue identified was the coding edit on codes 96160/96161 and the vaccine administration codes 90460-90461, 90471-90474. AAP clarified that edit is used when reporting two codes together, for instance 96160 and counseling code 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified healthcare professional; first or only component to each vaccine or toxoid administered). When appropriate, modifier 59 can be added on to either code 96160 or 96161 to override.

The California Academy of Family Physicians clarifies that: codes 96160 and 9616

  • Do not include interpretation or diagnoses
  • Include scoring and documentation
  • Is typically completed by a non-physician clinical staff member
  • Are valued by practice expense only

Reporting 90610 and 96161- Clinical examples

AAP and the California Academy of Family Physicians give various examples of situations when these new health risk assessment codes can be reported.

Risk Assessment CodesExample 1: If the mother is a patient (e.g., encounter for breastfeeding-related condition in the mother), the indications (i.e., symptoms vs. routine screening) for administration of a depression inventory will determine the code reported.

Report 96160 for the depression screen if the mother is the patient and depression is suspected.

Report 96161 if the encounter is focused on the baby and there is a concern for maternal depression and the Edinburgh postpartum screen is done. The maternal depression screen was added to the 2017 Recommendations for Preventive Pediatric Health Care and the service is billed under the baby, not the mother.

Example 2: Report 96160 when the CRAFFT tool is used to screen for alcohol or drug use.

Example 3: The California Academy of Family Physicians provides the following example for reporting 96161: An intellectually disabled patient is accompanied by his parent/caregiver at a preventive medicine service visit. The caregiver says that the patient is increasingly more difficult to manage and that things are falling apart at home.

Reliable medical coding service providers stay on top of CPT code changes and Medicare and commercial payer rules, and can help physicians report all services appropriately.