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Code deleted, see 96156, 96158, 96159

Official Description

Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; re-assessment

© Copyright 2026 American Medical Association. All rights reserved.

Common Language Description

The CPT® Code 96151 refers to a health and behavior assessment, which is a structured evaluation process aimed at understanding the interplay between a patient's health and their behavioral, emotional, and social factors. This assessment can be conducted by various qualified health care professionals, including physicians, psychologists, advanced practice nurses, and clinical social workers, all of whom possess specialized training in health and behavior assessment. The primary goal of this assessment is to identify biopsychosocial factors that may influence a patient's physical health, particularly in those suffering from acute or chronic illnesses or disabilities. During the assessment, the patient undergoes a comprehensive interview that covers their medical history, emotional state, and social circumstances. This process also includes evaluating the patient's capacity to manage issues related to their health conditions. To gather more detailed insights, standardized questionnaires are utilized, which may assess aspects such as anxiety levels, pain experiences, coping strategies, and other relevant factors that could affect the patient's overall health. Following the assessment, a tailored treatment plan is developed, incorporating health and behavioral interventions aimed at addressing the identified issues, including strategies to modify any social factors that may adversely impact the patient's health. It is important to note that the initial face-to-face assessment is coded under 96150, while subsequent face-to-face reassessments are reported using 96151, with each code applicable for every 15-minute increment of time spent in the assessment process.

© Copyright 2026 Coding Ahead. All rights reserved.

1. Indications

The health and behavior assessment (CPT® Code 96151) is indicated for patients who may be experiencing a range of health-related issues influenced by behavioral, emotional, or social factors. This assessment is particularly relevant for individuals with:

  • Acute Illnesses Patients suffering from sudden health conditions that may require a comprehensive understanding of their emotional and social contexts.
  • Chronic Illnesses Individuals with long-term health issues that necessitate ongoing evaluation of their coping mechanisms and behavioral responses.
  • Disabilities Patients with physical or mental disabilities that impact their health management and require tailored interventions.

2. Procedure

The procedure for conducting a health and behavior assessment involves several key steps that ensure a thorough evaluation of the patient's health and behavioral status. Each step is designed to gather comprehensive information that will inform the treatment plan.

  • Step 1: Initial Interview The process begins with a face-to-face interview where the healthcare professional engages the patient in a detailed discussion about their medical history, emotional well-being, and social circumstances. This initial interaction is crucial for establishing rapport and understanding the patient's unique situation.
  • Step 2: Behavioral Observations During the assessment, the healthcare provider observes the patient's behavior and interactions, noting any significant patterns or issues that may affect their health. These observations provide valuable context to the information gathered during the interview.
  • Step 3: Psychophysiological Monitoring If applicable, psychophysiological monitoring may be employed to assess the patient's physiological responses to stress or other health-related factors. This step can include measuring heart rate, blood pressure, or other relevant physiological indicators.
  • Step 4: Administration of Questionnaires Standardized health-oriented questionnaires are administered to the patient. These tools are designed to evaluate various aspects of the patient's experience, including anxiety levels, pain management, and coping strategies. The results from these questionnaires contribute to a more comprehensive understanding of the patient's health.
  • Step 5: Development of Treatment Plan Based on the information collected from the interview, observations, and questionnaires, the healthcare professional formulates a treatment plan. This plan includes specific health and behavioral interventions tailored to the patient's needs, as well as strategies to address any social factors impacting their health.

3. Post-Procedure

After the health and behavior assessment is completed, the patient may receive recommendations for follow-up care or additional interventions based on the findings. The healthcare provider may schedule subsequent reassessments to monitor the patient's progress and adjust the treatment plan as necessary. It is essential for the patient to engage in the recommended interventions and follow up with their healthcare provider to ensure optimal health outcomes. Continuous evaluation and support are critical, especially for patients managing chronic conditions or significant behavioral health challenges.

Short Descr ASSESS HLTH/BEHAVE SUBSEQ
Medium Descr HLTH&BEHAVIOR ASSMT EA 15 MIN W/PT RE-ASSMT
Long Descr Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; re-assessment
Status Code Active Code
Global Days XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 0 - No payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 0 - Payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Codes That May Be Paid Through a Composite APC
Type of Service (TOS) 9 - Other Medical Items or Services
Berenson-Eggers TOS (BETOS) M5D - Specialist - other
MUE Not applicable/unspecified.
CCS Clinical Classification 218 - Psychological and psychiatric evaluation and therapy
Date
Action
Notes
2019-12-31 Deleted Code deleted, see 96156, 96158, 96159
2011-01-01 Changed Short description changed.
2003-01-01 Changed Code description changed.
2002-01-01 Added First appearance in code book in 2002.
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Description
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