In January 2002, the Centers for Medicaid and Medicare services adopted six new codes reflecting health and behavior intervention services, and these were added to the Current Procedural Terminology (CPT®) code book (Table 8.1) [1, 13]. These “health and behavior” (H&B) codes are designed to address the behavioral, social, and psychophysiological procedures to prevent, treat, or manage physical health problems and are intended for use by non-physician healthcare clinicians operating within their scope of practice. This includes psychologists (PhDs), nurses (RN, NPs), and other non-physician specialists.

The H&B assessment procedures are offered to patients with an established illness or medical symptoms. The codes make it possible for psychologists and others to provide services to patients with chronic pain without having to diagnose the patient with some type of psychological disorder. In contrast to traditional psychological services, which must be paired with psychiatric diagnosis for billing, the H&B codes are psychological services that are paired with a medical diagnosis for billing. Consequently, it has been noted that, “Clinically, for the first time, practitioners working inside of medicine now have a tool to conceptualize psychology as medical service and have a mechanism to pay for it” [14].

It is noteworthy that, prior to CPT 2002, there was no way for psychologists to adequately capture these types of services. This sometimes led to ethical and professional quandaries for psychologists who worked in medical settings [15]. Medicare and other insurance companies have disallowed psychologists from using evaluation and management (E/M codes, CPT 99201–99205; 99211–99215; all CPT codes ©2012 American Medical Association. All rights reserved) on the basis of their training and the fact that these codes require medical management. Neuropsychological test codes (CPT 96100–96117) are not appropriate because they reflect testing of cognitive function and response of the central nervous system, which does not necessarily pertain to physical illness. Psychotherapy codes (CPT 90801–90809) are designed for use by psychologists and psychiatrists, but require a mental health diagnosis, which may not be present in medical patients. “The difficulties associated with acute or chronic medical illness, prevention of physical illness and disability, and maintenance of health, in many instances, do not meet criteria for a psychiatric diagnosis” [15]. Nonetheless, traditional psychotherapy codes were often used in this context, which could create a clinical dilemma. In the past, some providers used psychotherapy codes to bill for behavioral medicine services, as it was “administratively mandated,” while observing that it was also “not an accurate reflection of the patient encounter” [14]. Counseling and risk factor reduction codes (CPT 99401–99429) are not useful in this context as they require the absence of a physical health diagnosis, illness, or symptoms, which is clearly contraindicated for health and behavior interventions. In any case, these procedure codes are generally not reimbursable for psychologists. Similarly, psychological assessment codes (CPT 90801 for the interview and 96101–96103 for testing and report) were also developed in the context of a mental illness/psychiatric diagnosis. While appropriate for some clinical assessments of medical patients, they may be problematic if the primary assessment is related only to the medical condition and its impact on functioning (e.g., herniated lumbar disc, cancer-related pain), as opposed to identifying psychiatric disorders (e.g., depression, anxiety, addiction, or PTSD) or psychiatric complications (e.g., malingering or symptom magnification). It should be noted here though that the ICD-9-CM, the ICD-10-CM, and the DSM-IV-TR all include a diagnosis for “pain disorder,” which includes those patients whose pain reports are judged to be affected by psychosocial factors. Thus, for those patients exhibiting chronic pain with symptoms that exceed what would be expected given the objective medical findings, a diagnosis of pain disorder coupled with psychological assessment CPT codes may be applicable. These are discussed in greater detail below.

The principle advantage of health and behavior coding is that they allow psychologists to provide behavioral medicine services without utilizing psychiatric diagnoses. These codes were intended to be funded through medical, not mental, health carve outs, and this offers several advantages over traditional psychological service codes (CPT 90801–90806 and 96101–96103). Most importantly, health and behavior codes are not subject to Medicare’s “Outpatient Mental Health Treatment Limitation,” whereby Medicare reduces its copayment for mental health services from 80 to 50 %. This reduction only applies to services provided to outpatients with a “mental, psychoneurotic, or personality disorder identified by an ICD-9-CM diagnosis code between 290 and 319” [16]. As such, reimbursement for H&B codes occurs at a rate of 80 %, as it is considered a covered service under the medical portion of insurance. By 2014, though, it is expected that mental health services will be paid at the same 80 % level as physical health services [17]. Secondly, outside of Medicare, the use of psychological codes by psychologists will generally involve billing the mental health insurer, not the medical insurer, and the involvement of a second insurance company can add an additional complication administratively. Third, as above, the use of psychological codes requires a psychiatric diagnosis, and while psychiatric disorders are common in patients with chronic pain, they are not always present.