Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
| Contract | Contractor | Type | States |
|---|---|---|---|
| 11201 | Palmetto GBA | A and B and HHH MAC | SC |
| 11301 | Palmetto GBA | A and B and HHH MAC | VA |
| 11401 | Palmetto GBA | A and B and HHH MAC | WV |
| 11501 | Palmetto GBA | A and B and HHH MAC | NC |
| 11202 | Palmetto GBA | A and B and HHH MAC | SC |
| 11302 | Palmetto GBA | A and B and HHH MAC | VA |
| 11402 | Palmetto GBA | A and B and HHH MAC | WV |
| 11502 | Palmetto GBA | A and B and HHH MAC | NC |
| 10111 | Palmetto GBA | A and B MAC | AL |
| 10211 | Palmetto GBA | A and B MAC | GA |
| 10311 | Palmetto GBA | A and B MAC | TN |
| 10112 | Palmetto GBA | A and B MAC | AL |
| 10212 | Palmetto GBA | A and B MAC | GA |
| 10312 | Palmetto GBA | A and B MAC | TN |
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A56562 (Billing and Coding: Health and Behavior Assessment/Intervention) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A56562: Billing and Coding: Health and Behavior Assessment/Intervention (Billing and Coding, effective 2024-10-01)
- Covered ICD-10-CM codes
- 0
- 0 groups
- Non-covered ICD-10-CM codes
- 199
- Procedure codes listed
- 10
- Full article
- cms.gov record
Procedure codes: 96156, 96158, 96159, 96164, 96165, 96167, 96168, 96170, 96171, G2214 (Initial Or Subsequent Psychiatric Collaborative Care Management, First 30 Minutes In A Month Of Behavioral Health Care Manager Activities, In Consultation With A Psychiatric Consultant, And Directed By The Treating Physician Or Other Qualified Health Care Professional).
Coverage indications, limitations and medical necessity
The Health and Behavioral Assessment, Initial and Reassessment, and Intervention services may be considered reasonable and necessary for the patient who meets all of the following criteria:
• The patient has an underlying physical illness or injury, and
• There are indications that biopsychosocial factors may be significantly affecting the treatment or medical management of an illness or an injury, and
• The patient is alert, oriented and has the capacity to understand and to respond meaningfully during the face-to-face encounter, and
• The patient has a documented need for psychological evaluation or intervention to successfully manage his/her physical illness, and activities of daily living (ADLs), and
• The assessment is not duplicative of other provider assessments.
In addition, for a reassessment to be considered reasonable and necessary, there must be documentation that there has been a sufficient change in the mental or medical status warranting re-evaluation of the patient's capacity to understand and cooperate with the medical interventions necessary to their health and well-being.
Health and Behavioral Intervention with the family and patient present is considered reasonable and necessary for the patient if the family representative directly participates in the overall care of the patient.
Limitations
Health and Behavioral Assessment/Intervention will not be considered reasonable and necessary for the patient who:
• Does not have an underlying physical illness or injury, or
• For whom there is no documented indication that a biopsychosocial factor may be significantly affecting the treatment, or medical management of an illness or injury (i.e., screening medical patient for psychological problems), or
• Does not have the capacity to understand and to respond meaningfully during the face-to-face encounter, because of:
- Dementia that has produced a severe enough cognitive defect for the psychological intervention to be ineffective
- Delirium
- Severe and profound mental retardation
- Persistent vegetative state/no discernible consciousness
- Impaired mental status such as disorientation to person, time, place, purpose; inability to recall current season, location of own room, names and faces; inability to recall being in a nursing home or skilled nursing facility; or does not require psychological support to successfully manage their physical illness through identification of the barriers to the management of physical disease and ADLs.
Examples of Health and Behavioral Intervention services that are not covered and are not considered reasonable and necessary include:
• To provide family psychotherapy or mediation
• To maintain the patient's or family's existing health and overall well-being
• To provide personal, social, recreational, and general support services. Although such services may be valuable adjuncts to care, they are not medically necessary psychological interventions.
• Individual social activities
• Teaching social interaction skills
• Socialization in a group setting
• Vocational or religious advice
• Tobacco or caffeine withdrawal support
• Teaching the patient simple self-care
• Weight loss management
• Maintenance of behavioral logs
Summary of evidence (opening)
N/A
the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2018-01-29
- Current revision effective
- 2024-01-01
- Last reviewed by the contractor
- 2024-09-12
- MCD version
- 31
- Derived from
- L31300
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Palmetto GBA hub lists every other active policy from the same contractor.
Frequently asked questions
What does LCD L37638 cover?
The Health and Behavioral Assessment, Initial and Reassessment, and Intervention services may be considered reasonable and necessary for the patient who meets all of the following criteria: The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L37638 apply to?
Palmetto GBA applies it to Medicare claims in AL, GA, NC, SC, TN, VA, WV. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L37638?
The current export links no billing and coding article with a diagnosis list to this LCD, so coverage is decided on the indications in the policy text and the documentation in the record rather than by an automated diagnosis edit.
How do I appeal a denial under LCD L37638?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.