Practitioners Find Many Benefits in Using Health and Behavior Codes
by Communications Staff
February 10, 2005 -- Cheryl Shigaki, PhD, of Columbia, Mo., used to practice in an inpatient geriatric psychiatric hospital where patients frequently presented with a physical health diagnosis of Alzheimer’s disease and related behavioral problems. It wasn’t long ago that billing codes were unavailable for providing services to this population, even though they clearly can benefit from behavioral and environmental interventions.
“Many nursing homes were hesitant to take residents back unless they had some type of assessment and behavioral recommendations,” says Shigaki. “The residents ended up spending a lot of expensive time in acute psychiatric facilities.”
But the tide began to turn in January 2002. At that time, owing to the persistent efforts of the Practice Directorate and other key APA representatives, practicing psychologists gained the use of new "health and behavior" (H & B) Current Procedural Terminology (CPT)® codes. The H & B codes apply to psychological services that address behavioral, social, and psychophysiological conditions involved in treating or managing patients diagnosed with physical health problems. Before these codes were implemented, when psychologists helped patients cope with the challenges presented by physical illnesses, they had difficulty getting reimbursed unless the patient had a mental health diagnosis.
The H & B codes pertain to both assessment and intervention services. Descriptions of the six codes are found in the section of the American Medical Association’s CPT manual entitled, “Health and Behavior Assessment/Intervention.”
Practitioners who provide services related to the codes have found they can improve client health and functioning in many ways. Patients may be more likely to benefit from rehabilitation, adhere more closely to treatment plans, and engage in behaviors that help promote health.
Psychologists also say that H & B services facilitate patient adjustment to their physical illness. Edward Giaquinto, PhD, of North Hollywood, Calif., has found that helping patients become more aware of their illness enables them to better control certain aspects of their medical condition while reducing risk-related behaviors.
Thomas Reid, PsyD, principal psychologist with the multidisciplinary group Geriatric and Adult Psychiatry in Hamden, Ct., uses H & B codes in nursing home settings. He does consultation, largely around compliance issues – for example, working with a patient who refuses dialysis or to follow a diabetic protocol.
Some of the H & B services he provides involve circumstances and behaviors related to food and eating. For example, meals may be prepared and served in a way that residents aren’t used to. That prompts family members to bring in contraband items. Reid says the psychologist’s role in such a situation can involve refining the dietary regimen so it’s more palatable to the patient.
Dr. Reid finds that having the codes available also enables him to motivate patients to participate in physical and occupational therapy. He helps patients in short-term rehabilitation understand the value of physical therapy and the consequences of resisting it – for example, delaying their return to home. While Reid works with the patient to identify incentives for cooperating with the physical therapist, he also may help the therapist break down tasks into manageable steps that can be reinforced with the patient.
Similarly, Dr. Shigaki uses the H & B codes to address behavior that keeps patients from effectively engaging in therapies. For example, she might help a patient with a limb amputation who is experiencing significant anxiety about pain and falling during physical therapy and who wants to stay in bed all the time.
With such a patient, she may incorporate various approaches including formal breathing and relaxation, while also helping the client understand how participating in physical therapy can help reduce his or her anxiety. The effect may be to help foster greater independence and make the patient less likely to ask for unnecessary assistance from nursing staff. Dr. Shigaki also has found the codes helpful for providing or recommending interventions to facilitate rehabilitation in situations where a patient is so cognitively impaired that Shigaki could not provide and bill for psychotherapy.
Meanwhile, psychologists say they themselves are benefiting from providing H & B services -- which blend physical and psychological services delivery -- by engaging in a comprehensive approach to patient care. According to Dr. Reid, delivering H & B services has changed his interactions with other health care professionals. “I find myself more systematically incorporating other providers into discussions with clients (in the nursing home),” Reid says.
Dr. Giaquinto practices in a multispecialty clinic where primary care physicians refer patients with a variety of medical conditions to him and has also provided H & B services in long-term care facilities. He compiles information about a patient’s coping and problem solving skills, in addition to lifestyle factors such as diet and exercise, and provides individualized recommendations and/or interventions. Dr. Giaquinto says this personalized approach is aimed at making modifications to reduce risk-related behavior.
According to Giaquinto, the benefits of his H & B services accrue beyond the patient. The physicians with whom he collaborates tell him that they gain from his role in assisting patients with symptom management. For example, controlling stress with the aid of relaxation and deep breathing techniques can have a beneficial impact on heart rate and blood pressure, Giaquinto says.
Some of the H & B codes involve contact with family members. Through his interactions with family, Giaquinto says, “They benefit . . . by learning how the patient’s lifestyle affects (his or her) health, how they can assist the patient in managing their symptoms, and how the family may contribute to risk-related behavior (by the patient).”
Family members themselves can help stimulate appropriate H & B service delivery. According to Reid, though the physician ultimately approves consultation requests, it is not uncommon for patients’ relatives to initiate them. “Family members can be very helpful for noting failure to thrive and passive behaviors that are often overlooked by nursing home staff because [the behaviors] aren’t disruptive,” says Reid. For example, he observed, the family member is the one who is likely to point out that, ‘Mom isn’t doing the activities she used to do.’
For many psychologists, the benefits of using H & B service codes have extended beyond client care to include practice finances. All Medicare carriers except in Florida pay for psychologists’ services under the health and behavior codes. At least 17 private insurance carriers are now accepting these codes, and the number continues to grow.
According to utilization data from the U.S. Centers for Medicare and Medicaid Services (CMS), Medicare reimbursement to psychologists for H & B services topped $6 million in 2003 -- a fourfold increase from approximately $1.5 million in payments the year before. Medicare carriers pay for the codes at the same 80/20 copayment level as medical services are reimbursed. The “Outpatient Mental Health Treatment Limitation,” whereby Medicare reduces its copayment for mental health services from 80% to 50%, does not apply to H & B services.
Dr. Giaquinto started using the CPT codes for H & B services last year. “It’s helped me receive reimbursement for these beneficial services and increased my overall revenue by 25 percent,” he says.
Adding an historical perspective, Dr. Reid says that before the H & B codes became available in 2002, much of the same work for which he now bills using these codes had to be done. But he didn’t feel he could bill for the services before there were appropriate CPT codes. “Now I don’t have to sacrifice significant amounts of time providing non-reimburseable services,” says Reid.
Other trends besides reimbursement patterns may help fuel increased use of the H & B codes. Dr. Shigaki sees them as particularly beneficial given demographic trends in the United States. “With the aging population, better care – and less drug dependent care – for individuals with progressive dementia is a huge and pressing issue,” she says.
Current Procedural Terminology© 2005 American Medical Association. All Rights Reserved.
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