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See a sample rate comparisonCPT 96165 Fee Schedule
Last Verified: October 2026
Healthcare providers use this code to document and receive reimbursement for visits that address moderate-level medical decision-making, often including multiple diagnoses or prescription management.
Level 4 Hospital Emergency Department Visit Provided In A Type B Emergency Department; (The Ed Must Meet At Least One Of The Following Requirements: (1) It Is Licensed By The State In Which It Is Located Under Applicable State Law As An Emergency Room Or Emergency Department; (2) It Is Held Out To The Public (By Name, Posted Signs, Advertising, Or Other Means) As A Place That Provides Care For Emergency Medical Conditions On An Urgent Basis Without Requiring A Previously Scheduled Appointment; O
| Key Fact | Detail |
|---|---|
| Service Type | Medicine Services and Procedures Health Behavior Assessment and Intervention Procedures |
| Common Place of Service | 11 - Office 57 - Non-residential Substance Abuse Treatment Facility 99 - Other POS |
| Common Modifiers | HF U2 |
| Complexity Level | Low |
| Medicare Fee Schedule | $5.01 national non-facility rate (2026) · View Medicare rates for 96165 |
| Medicaid Fee Schedule | $4.14 median of the 8 states in the free preview · View Medicaid rates for 96165 |
National average reimbursement for CPT 96165 by major payers:
$5.95
$4.42
$5.87
$14.36
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CPT 96165
5 of 25 sample ratesHigher to lower in this preview
Andrea Greseth
Allina Health System
$16.82Published rateEllen Stoll
Allina Health System
$16.82Published rateHannah Sayner
Allina Health System
$16.82Published rateDavid Monyak
Allina Health System
$16.82Published rateConcepcion Santillan
Allina Health System
$12.14Published rate
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See a sample payer proposalCPT 96165 vs. Other Health Behavior Assessment and Intervention Procedures Codes
The CPT 96165 code is part of the Medicine Services and Procedures services used for Health Behavior Assessment and Intervention Procedures. It represents a moderate-complexity encounter and is one of several codes that vary based on time spent, level of medical decision-making, and documentation requirements.
The CPT 96165 code involves more provider time and moderate medical decision-making, unlike lower-level codes that require less time and simpler assessments. It typically includes multiple diagnoses, medication management, or test interpretation, leading to higher reimbursement and more detailed documentation requirements.
| Code | Complexity | Description |
|---|---|---|
| 96165-CPT | Low | Level 4 Hospital Emergency Department Visit Provided In A Type B Emergency Department; (The Ed Must Meet At Least One Of The Following Requirements: (1) It Is Licensed By The State In Which It Is Located Under Applicable State Law As An Emergency Room Or Emergency Department; (2) It Is Held Out To The Public (By Name, Posted Signs, Advertising, Or Other Means) As A Place That Provides Care For Emergency Medical Conditions On An Urgent Basis Without Requiring A Previously Scheduled Appointment; O |
| 96167-CPT | Low | Level 5 Hospital Emergency Department Visit Provided In A Type B Emergency Department; (The Ed Must Meet At Least One Of The Following Requirements: (1) It Is Licensed By The State In Which It Is Located Under Applicable State Law As An Emergency Room Or Emergency Department; (2) It Is Held Out To The Public (By Name, Posted Signs, Advertising, Or Other Means) As A Place That Provides Care For Emergency Medical Conditions On An Urgent Basis Without Requiring A Previously Scheduled Appointment; O |
| 96168-CPT | Low | Initial Physician Evaluation And Management Of A Diabetic Patient With Diabetic Sensory Neuropathy Resulting In A Loss Of Protective Sensation (Lops) Which Must Include: (1) The Diagnosis Of Lops, (2) A Patient History, (3) A Physical Examination That Consists Of At Least The Following Elements: (A) Visual Inspection Of The Forefoot, Hindfoot, And Toe Web Spaces, (B) Evaluation Of A Protective Sensation, (C) Evaluation Of Foot Structure And Biomechanics, (D) Evaluation Of Vascular Status And Ski |
| 96170-CPT | Low | Follow-Up Physician Evaluation And Management Of A Diabetic Patient With Diabetic Sensory Neuropathy Resulting In A Loss Of Protective Sensation (Lops) To Include At Least The Following: (1) A Patient History, (2) A Physical Examination That Includes: (A) Visual Inspection Of The Forefoot, Hindfoot, And Toe Web Spaces, (B) Evaluation Of Protective Sensation, (C) Evaluation Of Foot Structure And Biomechanics, (D) Evaluation Of Vascular Status And Skin Integrity, And (E) Evaluation And Recommendat |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 96165. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 96165 fee schedule helps patients estimate costs and providers optimize billing for accurate reimbursements.
Factors that affect fee schedules
Medicare & Medicaid Rates
Government-set reimbursement amounts
Private Insurance Rates
Negotiated rates between providers and insurance companies
Geographic Location
Costs may be higher in urban areas.
Provider Type
Hospital providers may have different rates than private practice.
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