Billing code 96158: Health behaviorMedicare rate & RVUs in Illinois
Report 96158 for an individual face-to-face intervention addressing behavioral or psychosocial factors that affect a patient’s physical health or medical treatment.
Medicare pays $72.43–$74.95 for 96158 in the office in Illinois, from Rest Of Illinois to Suburban Chicago. Which amount applies depends on the service address.
Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.
On this page 9 sections
What 96158 covers
A qualified health professional works face-to-face with one patient to change behaviors or address psychosocial factors affecting a physical health condition, its treatment, or recovery. Common situations include helping a patient with chronic pain use coping strategies, supporting adherence to a diabetes treatment plan, or addressing behavior changes related to cardiovascular disease. Psychologists, clinical social workers, and other qualified professionals may provide the service in primary care or specialty medical settings.
Report 96158 for the initial 30 minutes of individual intervention with the patient. The note should identify the health condition or treatment-related concern, the behavioral intervention provided, the patient’s participation, and the time spent. Use 96159 for qualifying additional time. CMS assigns work, practice expense, and malpractice relative values; the practice-expense value differs between office and facility settings.
This summary was written with AI assistance from CMS physician fee schedule data and checked against the CMS billing rules shown here. Rates on this page come directly from CMS files.
Where 96158 pays more and less in Illinois
The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.
4 payment localities
$72.43 to $74.95
| Payment locality | Office | Facility |
|---|---|---|
| Chicago | $74.73 | $60.63 |
| East St. Louis | $72.71 | $59.81 |
| Rest Of Illinois | $72.43 | $59.63 |
| Suburban Chicago | $74.95 | $60.54 |
How the 96158 rate is calculated
Each of 96158’s three RVUs is multiplied by a geographic index (GPCI) for the payment locality, added up, and multiplied by the conversion factor. Drag the indexes or enter a ZIP to see what moves the rate.
How the rate is built · 96158
RVUs × geographic indexes × conversion factor
Swap in your local Medicare rate.
Work 1.66Practice expense 0.54Malpractice 0.01
All indexes start at 1.000 (the national rate). Enter a ZIP or drag a slider.
Payment rules and modifiers for 96158
96158 has no global surgery period, no multiple-procedure, bilateral or assistant-at-surgery adjustment, and no professional/technical split. What changes the payment is where the service happens: the place of service on the claim decides whether Medicare pays the office or the facility rate.
Place of service · 96158
Which rate does Medicare pay?
The POS code on the claim line (CMS-1500 box 24B).
Non-facility (office) rate · national
$73.82
The facility rate would be $59.79 (+$14.03). In a facility, the facility bills its own costs separately.
96158 compared with similar codes
Compare codes
96158 vs 96156 vs 96159 vs 96164 vs 90832: national Medicare rates
Swap in your local Medicare rate.
How to choose
- 96156Health behavior assessment
- 96156 is for health behavior assessment or reassessment; 96158 is for the intervention addressing the identified behavioral or psychosocial concern.
- 96159Health behavior intervention
- 96158 covers the initial 30 minutes of individual intervention; 96159 is used for qualifying additional time.
- 96164Group intervention
- Use 96158 for an individual patient intervention. Use 96164 when the health behavior intervention is delivered in a group.
- 90832Psychotherapy session
- 90832 describes psychotherapy. 96158 addresses behavior or psychosocial factors affecting physical health or medical treatment.
96158 billing questions
How is 96158 different from 96156?
96156 describes a health behavior assessment or reassessment. Use 96158 when the service is an intervention intended to address behavioral or psychosocial factors affecting physical health or treatment.
When should 96159 be reported with 96158?
96158 represents the initial 30 minutes of individual intervention. Report 96159 for qualifying additional time, and document the time and intervention provided.
Can 96158 be used for a group session?
No. 96158 is for individual intervention with the patient. Group health behavior intervention is represented by 96164 for its initial time.
How does 96158 differ from psychotherapy?
96158 addresses behavioral or psychosocial factors that affect a physical health condition or its treatment. Psychotherapy codes describe treatment directed at a mental health condition.
What should the record support?
Document the physical health or treatment-related concern, the intervention and patient participation, and the time spent. The note should show that an individual face-to-face intervention was performed.
Where these rates come from
FeeBase calculates base physician payments from CMS work, practice-expense and malpractice RVUs, adjusted by each locality’s geographic indexes and the conversion factor. Services without a published rate are labeled, never given a made-up amount. Amounts are Medicare allowed amounts before claim adjustments: not a patient’s bill or a commercial rate.
CMS RVU26D · effective Oct 1, 2026 through the day before Jan 1, 2027
Show the CMS file lines behind this rate
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