CMS Health and Behavior Assessment/Intervention Form

Summary Of Evidence

N/A

Analysis of Evidence

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 are 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