Basics of CPT code 96160 and 96160
A provision in the Patient Protection and Affordable Care Act of 2010 (ACA) established a Medicare Wellness Visit, which included a Health Risk Assessment (HRA) and customized wellness or prevention plan. HRAs are typically completed by a patient or caregiver prior to the encounter with a physician or other qualified health care professional, but can involve the assistance of the clinician and/or staff members.
The HRA tool is purposefully designed to be brief, straightforward, and easy to comprehend with questions such as patient demographic information, personal and/or family history, a self-assessment of how the patient interprets his/her health to be, risk factors, biometric measurements, and compliance. Completion of the HRA tool takes approximately 20 minutes and may be done via the internet or on a paper-based document. Assessments that emphasize a patient or caregiver focus may be referred to as HRA plus assessments and as such should be person centered and culturally appropriate in all areas, including, but not limited to, the assessment instrument, the administration process of the assessment, clinician communication with the patient regarding findings, as well as follow up and monitoring.
Additionally, the patient-focused HRA takes into consideration the importance of care support services over and above the health care system; for example, by family members, community support services, or even in the workplace setting where the individual receiving care is not deemed to be a “patient.” An emphasis is also placed on cultural competency as means of limited health disparities through respect of the patient’s beliefs and understanding the mental and physical ways a patient can experience illness and health and working together to establish a health plan. Another area of patient-focused care involves areas of importance to patients as consumers, such as convenience as well as increasing outcomes that matter to patients; for example, improved quality of life and function.
Similarly, caregiver-focused assessment tools serve to identify areas of concern such as stress levels, depression, and the burdens placed on the caregiver. HRAs contribute to the goals of the government to drive health improvements, quality of life, and value for the health care delivery system in the United States. CPT code 96160 is reported for administration of a patient-focused health risk assessment tool and CPT 96161 for administration of a caregiver-focused assessment tool. Both codes include scoring and documentation of the assessment tool.
It is important to note that codes 96160 and 96161 do not include physician work and are related only to practice expense, including clinical staff work, supplies and equipment expenses. Services provided by the physician or other qualified health care professional are included in the E/M code, which may be reported for the patient encounter. The separately reported E/M service includes interpreting the rating scale, discussing the results with the patient and/or caregiver, documenting the patient/caregiver discussion in the patient’s medical record, and providing any referrals to the parent’s or caregiver’s primary care provider or mental health provider.
Codes 96160 and 96161 will allow reporting patient risk-assessment instrument administered to either the patient or the caregiver/parent in order to assess the risk of conditions, such as mental disorders, when performed in conjunction with an E/M visit.
Sample coded report for 96161
Chief Complaint
Patient presents with
• Well Child
• Cold Symptoms
In person Spanish interpretor used for the entirety of this visit.
SUBJECTIVE:
6 m.o. male brought in by mother and father for routine check up.
Parental concerns: He has had a cold for about 1 week. Had a fever on Saturday but none since. He is coughing but this seems to have gotten a little better over the week. He is also congested and taking about 1-2 oz less per bottle than usual.
Home: lives with mother and father, Maternal grandparents and maternal uncle
Diet: Similac 4-5oz about 4-4 times per day, takes one Gerber baby food per day, no reactions
Elimination: No concerns. Numerous wet diapers per day. Soft stools.
Dental: does have teeth. Two bottom teeth.
does not brushes teeth.
does not use fluoride toothpaste.
does not have a dental home.
Sleep: Sleeping on back in crib.
Safety: Smokers in home-No. Rear facing car seat- Yes. Lead risk-No. Guns in home: no.
Development: No parental concerns. Can roll both ways and sit up with support. Passes an object between hands and is babbling and laughing.
In the last 12 months, did you worry whether food would run out before you got money to buy more? never
In the last 12 months, did the food you bought not last and you didn’t have the money to get more? never
Do you receive SNAP benefits? not evaluated
Review of Systems
Constitutional: Negative for fever and malaise/fatigue.
HENT: Positive for congestion.
Eyes: Negative for discharge and redness.
Respiratory: Positive for cough. Negative for shortness of breath and wheezing.
Gastrointestinal: Negative for diarrhea and vomiting.
Skin: Negative for rash.
OBJECTIVE:
Pulse 136, temperature 97.7 °F (36.5 °C), temperature source Temporal, resp. rate 42, height 69.5 cm, weight 10.4 kg (22 lb 14 oz), head circumference 17.52″ (44.5 cm).
Physical Exam
Vitals reviewed.
Constitutional:
General: He is active.
HENT:
Head: Normocephalic. Anterior fontanelle is flat.
Nose: Congestion present.
Comments: Audible congestion
Mouth/Throat:
Mouth: Mucous membranes are moist.
Pharynx: Oropharynx is clear.
Eyes:
General: Red reflex is present bilaterally.
Right eye: No discharge.
Left eye: No discharge.
Conjunctiva/sclera: Conjunctivae normal.
Cardiovascular:
Rate and Rhythm: Normal rate and regular rhythm.
Heart sounds: Normal heart sounds. No murmur heard.
Pulmonary:
Effort: Pulmonary effort is normal. No nasal flaring or retractions.
Breath sounds: Transmitted upper airway sounds (heard throughout) present. No stridor. No wheezing, rhonchi or rales.
Abdominal:
General: Bowel sounds are normal. There is no distension.
Palpations: Abdomen is soft. There is no mass.
Genitourinary:
Penis: Uncircumcised.
Testes: Normal.
Musculoskeletal:
Cervical back: Neck supple.
Right hip: Negative right Ortolani and negative right Barlow.
Left hip: Negative left Ortolani and negative left Barlow.
Skin:
General: Skin is warm.
Capillary Refill: Capillary refill takes less than 2 seconds.
Findings: No rash.
Comments: Small <1cm hemangioma to the right side overlying ribs, per parents no change in size since about 3 months of age
Neurological:
Mental Status: He is alert.
Motor: No abnormal muscle tone.
ASSESSMENT:
6 month WCC with abnormal findings of nasal congestion and cough most likely consistent with viral URI and right OM found on exam.
PLAN:
Viral URI
– Discussed supportive care. Nasal saline and suction as needed.
– Discussed return precautions
Acute Right OM
– Complete full course of Amoxil
– Discussed return precautions
Immunizations reviewed and brought up to date per orders. First flu vaccine given today.
Dental: Patient is a candidate for in-office fluoride varnish application. Deferred as patient only with two teeth. Counseled on proper brushing BID with fluoride toothpaste.
Counseling: development, feeding, fever, immunizations, safety, and well care schedule. Given 6 month handout.
Follow up in 3 months for well care.
CPT codes
99391 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age younger than 1 year)
96161 Administration of caregiver-focused health risk assessment instrument (eg, depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument
ICD-10 code
Z00.129 – Encounter for routine child health examination without abnormal findings
H66.91 – Otitis media, unspecified, right ear [Active]
J06.9 – Acute upper respiratory infection, unspecified [Active]
D18.01 – Hemangioma of skin and subcutaneous tissue [Active]