Psychological Assessments and Pain Care Planning: Use & Coding Considerations

The Role of Screening Tools

According to The National Institute of Mental Health, “People with other chronic medical conditions have a higher risk of depression.”1  To that end, there is a high probability that any person with a chronic pain condition has a concomitant psychological disorder, most notably depression and/or anxiety. The relationship between chronic pain and depression/anxiety is well established. The causal link between pain and these disorders can point in either direction and over time may form a positive feedback loop between these two elements.

Screening tools are available that will aid in the detection of potential depression/anxiety, and when indicated, a referral may be most appropriate for more extensive evaluation and treatment. In addition, lesser psychological factors such as catastrophizing and fear avoidance behavior may interfere with a patient’s recovery and should be recognized by the clinician. Recognizing indicators of patient psychosocial health behavioral factors can affect a patient’s recovery and/or compliance with treatment and may decrease the risk of developing chronic illness/pain. Tools such as the PROMIS-29, Pain Catastrophizing Scale, and PHQ-9 depression scales are examples.

  • The clinically-validated PROMIS-29 multidimensional pain scale is used to detect changes in pain, anxiety, depression, physical function, sleep and quality of life.
  • The Pain Catastrophizing Scale is broken into three sub-scales being magnification, rumination, and helplessness. The scale was developed as a self-report measurement tool that provided a valid index of catastrophizing in clinical and non-clinical populations.
  • The PHQ-9 is a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression.

CPT Considerations

(NOTE: These are not coding recommendations by Celéri Health.  Please verify with your revenue cycle consultant, revenue cycle team,, provider manuals/policies per carrier contract, etc)

  • 96127 – Brief emotional/behavioral assessment (eg, depression inventory, attention deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument
  • G0444 – Annual depression screening, 15 minutes (ALERT – Only an annual report is allowed)

Regardless of the code used, the following information should likely be included in the documentation:

  • Type of screening tool used (e.g., PROMIS-29, PHQ-9)
  • Results of the screening.
  • Some payers may want to see the member’s responses in addition to the score so be sure to keep the responses in case the payer requests that information.
  • Your Impression/plan, considering the results from the screener. If the screening is positive, there needs to be documentation of the planned treatment and how the known result of anxiety or depression or other behavioral interference plays into your pain management care plan.

Other Common Questions

  • Can You Use CPT 96127 With Telemedicine Services?
    Using this code for telemedicine depends on the conditions of the payer. For many providers, including Medicare, you can bill CPT 96127 through telemedicine services. Keep in mind that for some, this is a temporary addition due to COVID-19 and may change in the future.
  • How Should I Bill CPT 96127 if the Test Was Scored on Another Day?
    Since this code encompasses administration and scoring, you should report it with the date those services were completed.
  • Should I Use Modifiers With CPT 96127?
    Depending on the payer, you may need to use modifier 59 to indicate the screening was distinct or independent from other non-evaluation and management services. Include documentation to support.


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