In simple words: This service helps understand how a patient's thoughts, feelings, and behaviors influence their physical health. The doctor observes the patient, asks questions about their health and how it affects their life, and may use questionnaires to gather information.This helps create a plan to improve the patient's overall well-being.

This code encompasses the assessment or re-assessment of health behavior through methods like health-focused clinical interviews, behavioral observations, and clinical decision-making. It aims to evaluate a patient's responses to disease, illness, or injury, including their outlook, coping mechanisms, motivation, and adherence to medical treatment. The focus is on psychological and psychosocial factors impacting physical health, not on diagnosing mental health disorders.

Example 1: A patient with chronic pain exhibits anger and resistance towards prescribed physical therapy. Code 96156 is used to assess the psychological factors contributing to non-adherence., A patient recently diagnosed with diabetes struggles to adapt to lifestyle changes. A health behavior assessment is conducted using 96156 to understand barriers to self-management., A cancer patient experiences anxiety and fear, impacting their ability to cope with treatment. Code 96156 allows assessment of these factors to develop targeted interventions.

Documentation should support the medical necessity of the assessment, linking the psychological and/or psychosocial factors to the patient's physical health condition. Details of the clinical interview, behavioral observations, and clinical decision-making should be recorded.