CPT 96127 Billing and Usage Guide

What is CPT 96127?

CPT code 96127 (Brief emotional/behavioral assessment) has only been around since early 2015, and has been approved by the Center for Medicare & Medicaid Services (CMS) and is reimbursed by major insurance companies, such as Aetna, Anthem, Cigna, Humana, United Healthcare, Medicare and others. 

Why was CPT 96127 developed and how is it used?

It was created as part of the ACA’s federal mandate to include mental health services as part of the essential benefits package now required in all insurance plans.  Patients can be screened and billing submitted for the following visits: post hospitalization, new diagnosis or complex medical issue, patients with pain, patients with substance abuse, and patients diagnosed with or being treated for mental illness. 

When can I bill for CPT 96127?

CPT 96127 can be billed on the same date of service as other common services such as psychiatry or therapy appointments and is appropriate when used as part of a standard clinical intake.  Primary care and other specialists may use CPT code 96127 when screening and assessing their patients, up to four times per year per patient. 

What mental health conditions does it cover?

It should be used to report a brief assessment for ADHD, depression, suicidal risk, anxiety, somatic symptom disorder and substance abuse and can be billed up to 4 times per year, with a maximum of 4 different screens per visit, but this may vary based on insurance provider. 

What is the appropriate date of service to use for CPT code 96127?

The appropriate date of service for CPT 96127 will be the date that the service was completed.  Since CPT code 96127 includes scoring and documentation of the test, you would need to report the date that the testing concluded.  The provider does not need to be the one to administer the assessment, since the code description also references scoring and documenting the result.  The provider reporting the service should be the one who is interpreting the results of the assessment.

Please see the CMS documentation for additional information and circumstances: 

Use a modifier 59 with CPT code 96127?

Each insurance is different. Most insurances require modifier 59 when using CPT code 96127. 

Please check with each insurance provider for specific guidelines.

Under certain circumstances, a physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician.

Most payers may require that modifier 59 is appended to the screening code.  If multiple screenings are performed on a date of service CPT 96127 should be reported with the number of test as the number of Units.  

NOTE:  Modifier 25 should be appended to the E/M and modifier 59 should be appended to the 96127 CPT code. 

For Example:

  • 99214 25

  • 96127 59 2 Units

Please see the CMS documentation for additional information and circumstances: 

Can I bill CPT codes CPT 96103 or CPT 96101 with CPT 96127?

Medicare will not allow you to bill 96127, 96101 and 96103 on the same visit, however, each insurance is different.  

Please check with each insurance provider for specific guidelines.

CPT code 96103 (Testing & Interpretation Psychological testing administered by a computer) requires that each administration of an assessment is medically necessary and the report justifies the necessity of each billed assessment. 

CPT 96101 (Integration of Additional information by Physician per hour of the qualified healthcare professional time) reimburses for the provider’s time administering, interpreting assessments, and for the additional time needed to integrate assessment results with other information about the patient, provided that it does not include the time used in conjunction with the administration of an assessment billed out under CPT 96103.

When a provider performs some tests and a technician or computer performs other tests, documentation must demonstrate medical necessity for all tests.  The provider time spent on the interpretation of the tests performed by the technician/computer may not be added to the units billed under CPT code 96101. Medicare will not pay twice for the same test or the interpretation of tests. 

Additional Note: Certain insurances will consider screening and assessments as bundled services and may not pay separately for each.

Is CPT 96127 under the ‘no cost-sharing provision’ in the ACA?

Only those services performed as part of a routine screening service are covered as part of the ACA no cost sharing.  However, when 96127 is performed and reported as part of a diagnostic service (i.e., a problem is suspected) or when the screen is done outside of the routine recommendations (i.e., more than the recommendations stipulate), the code may fall under a cost sharing arrangement.  Note that, any plan not required to follow ACA provisions will have their own rules on this. One way to ensure that behavioral/emotional screen service is covered under ACA provisions is to link the service to either the preventive ICD code or the “screening for” code.  The patient must be asymptomatic in-order-to report the “screening for” ICD code Z13.89.

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