2025 CPT code 96161
(Active) Effective Date: N/A Medicine - Health Behavior Assessment and Intervention Feed
Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument.
Modifiers may be applicable to further specify the circumstances of the service.
Medical necessity is established by the patient's underlying condition and the potential impact of the caregiver's health risks on the patient's well-being or care plan.
The provider administers the assessment, analyzes results, discusses findings with the caregiver, and documents the process.
In simple words: A healthcare provider gives a questionnaire to the patient's caregiver to help identify potential health concerns. The provider then reviews the answers, explains the results to the caregiver, and keeps a record of everything.
The provider administers a standardized questionnaire to a patient's caregiver to assess specific health risks, analyzes the responses, scores the assessment, and documents the findings. This code is used for each standardized instrument administered.
Example 1: A physician administers a depression screening questionnaire to the caregiver of a patient with a chronic illness to assess the caregiver's risk and potential impact on the patient's care., A social worker uses a standardized stress assessment tool with the caregiver of a child with developmental delays to evaluate caregiver burden and identify support needs., A nurse practitioner administers a caregiver burden inventory to the spouse of a patient with Alzheimer's disease to assess the level of strain and connect them with appropriate resources.
Documentation should include the name of the standardized instrument used, the date of administration, the caregiver's score, and a summary of the discussion of results with the caregiver. Any recommendations or referrals made should also be documented.
- Specialties:Primary care, specialty physicians providing ongoing care for chronic conditions, social work, nursing
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Home, Skilled Nursing Facility, Nursing Facility