In simple words: This code covers additional time spent with a healthcare professional working with you one-on-one to address how your thoughts, feelings, and behaviors might be affecting a physical health condition you have. This is not for mental health conditions, but rather how these factors might be making it harder to manage a physical illness.

This add-on code is used for each additional 15 minutes of health behavior intervention provided to an individual patient, face-to-face.It must be reported in addition to the primary service code (96158).

Example 1: A patient with diabetes struggles with adherence to their diet and medication regimen.After an initial 30 minutes (96158), the provider spends an additional 20 minutes working with the patient on strategies to improve self-management, justifying the use of 96159., A patient with chronic pain has difficulty coping with the impact of pain on their daily life.Following the initial 30 minutes (96158), the provider spends an additional 15 minutes teaching relaxation techniques and pain management strategies, justifying 96159., A patient recovering from a stroke is experiencing emotional difficulties adjusting to their physical limitations. The provider spends 45 minutes working with the patient on emotional adjustment and coping strategies. The first 30 minutes is coded 96158, and the additional 15 minutes are coded 96159.

Documentation should support the medical necessity of the health behavior intervention and the total time spent with the patient. It should also clearly indicate the connection between the psychological/behavioral factors and the patient's physical health condition. The specific interventions used and the patient's response should be documented.