Health and Behavior Assessment/Intervention

LCD Information Document Information Source LCD ID N/A LCD ID L37638 Original ICD-9 LCD ID Not Applicable LCD Title Health and Behavior Assessment/Intervention Proposed LCD in Comment Period N/A Source Proposed LCD N/A Original Effective Date For services performed on or after 01/29/2018 Revision Effective Date For services performed on or after 01/01/2024 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date 12/14/2017 Notice Period End Date 01/28/2018 CPT codes, descriptions, and other data only are copyright 2025 American Medical Association. All Rights Reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association. 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Issue Issue Description This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity. Issue - Explanation of Change Between Proposed LCD and Final LCD CMS National Coverage Policy Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member Title XVIII of the Social Security Act, §1862(a)(7) excludes routine physical examinations Coverage Indications, Limitations, and/or Medical Necessity The Health and Behavioral Assessment, Initial and Reassessment, and Intervention services may be considered reasonable and necessary for the patient who meets all of the following criteria: The patient has an underlying physical illness or injury, and There are indications that biopsychosocial factors may be significantly affecting the treatment or medical management of an illness or an injury, and The patient is alert, oriented and has the capacity to understand and to respond meaningfully during the face-to-face encounter, and The patient has a documented need for psychological evaluation or intervention to successfully manage his/her physical illness, and activities of daily living (ADLs), and The assessment is not duplicative of other provider assessments. In addition, for a reassessment to be considered reasonable and necessary, there must be documentation that there has been a sufficient change in the mental or medical status warranting re-evaluation of the patient's capacity to understand and cooperate with the medical interventions necessary to their health and well-being. Health and Behavioral Intervention with the family and patient present is considered reasonable and necessary for the patient if the family representative directly participates in the overall care of the patient. Limitations Health and Behavioral Assessment/Intervention will not be considered reasonable and necessary for the patient who: Does not have an underlying physical illness or injury, or For whom there is no documented indication that a biopsychosocial factor may be significantly affecting the treatment, or medical management of an illness or injury (i.e., screening medical patient for psychological problems), or Does not have the capacity to understand and to respond meaningfully during the face-to-face encounter, because of: - Dementia that has produced a severe enough cognitive defect for the psychological intervention to be ineffective - Delirium - Severe and profound mental retardation - Persistent vegetative state/no discernible consciousness - Impaired mental status such as disorientation to person, time, place, purpose; inability to recall current season, location of own room, names and faces; inability to recall being in a nursing home or skilled nursing facility; or does not require psychological support to successfully manage their physical illness through identification of the barriers to the management of physical disease and ADLs. Examples of Health and Behavioral Intervention services that are not covered and are not considered reasonable and necessary include: To provide family psychotherapy or mediation To maintain the patient's or family's existing health and overall well-being To provide personal, social, recreational, and general support services. Although such services may be valuable adjuncts to care, they are not medically necessary psychological interventions. Individual social activities Teaching social interaction skills Socialization in a group setting Vocational or religious advice Tobacco or caffeine withdrawal support Teaching the patient simple self-care Weight loss management Maintenance of behavioral logs Summary of Evidence N/A Analysis of Evidence (Rationale for Determination) N/A

The Health and Behavioral Assessment, Initial and Reassessment, and Intervention services may be considered reasonable and necessary for the patient who meets all of the following criteria: The patient has an underlying physical illness or injury, and There are indications that biopsychosocial factors may be significantly affecting the treatment or medical management of an illness or an injury, and The patient is alert, oriented and has the capacity to understand and to respond meaningfully during the face-to-face encounter, and The patient has a documented need for psychological evaluation or intervention to successfully manage his/her physical illness, and activities of daily living (ADLs), and The assessment is not duplicative of other provider assessments. In addition, for a reassessment to be considered reasonable and necessary, there must be documentation that there has been a sufficient change in the mental or medical status warranting re-evaluation of the patient's capacity to understand and cooperate with the medical interventions necessary to their health and well-being. Health and Behavioral Intervention with the family and patient present is considered reasonable and necessary for the patient if the family representative directly participates in the overall care of the patient. Limitations Health and Behavioral Assessment/Intervention will not be considered reasonable and necessary for the patient who: Does not have an underlying physical illness or injury, or For whom there is no documented indication that a biopsychosocial factor may be significantly affecting the treatment, or medical management of an illness or injury (i.e., screening medical patient for psychological problems), or Does not have the capacity to understand and to respond meaningfully during the face-to-face encounter, because of: - Dementia that has produced a severe enough cognitive defect for the psychological intervention to be ineffective - Delirium - Severe and profound mental retardation - Persistent vegetative state/no discernible consciousness - Impaired mental status such as disorientation to person, time, place, purpose; inability to recall current season, location of own room, names and faces; inability to recall being in a nursing home or skilled nursing facility; or does not require psychological support to successfully manage their physical illness through identification of the barriers to the management of physical disease and ADLs. Examples of Health and Behavioral Intervention services that are not covered and are not considered reasonable and necessary include: To provide family psychotherapy or mediation To maintain the patient's or family's existing health and overall well-being To provide personal, social, recreational, and general support services. Although such services may be valuable adjuncts to care, they are not medically necessary psychological interventions. Individual social activities Teaching social interaction skills Socialization in a group setting Vocational or religious advice Tobacco or caffeine withdrawal support Teaching the patient simple self-care Weight loss management Maintenance of behavioral logs