CPT Code 96161: Caregiver-Completed Health Risk Assessment

What is a caregiver-completed health risk assessment?

CPT code 96161 is used to report the administration of a caregiver-completed health risk assessment instrument, performed for the benefit of the patient. This screening and assessment code is applied when the patient is unable or too young to complete a standardized screening tool themselves, and a caregiver—such as a parent or legal guardian—completes the tool to help the provider evaluate the patient's emotional and behavioral health or developmental status. This is common in pediatric care, postpartum depression screening, and some geriatric evaluations.

Standardized instruments used under CPT code 96161 must be validated and appropriate for clinical use. Examples include the Pediatric Symptom Checklist, developmental milestone survey, or a risk assessment instrument(e.g., depression inventory, health hazard appraisal). These tools are used to identify behavioral health conditions, generalized psychosocial symptoms, or developmental concerns in patients.

When to use CPT code 96161

CPT 96161 should be used during visits when caregivers provide relevant responses using a structured screening instrument. These include:

• Caregiver-focused health risk assessments
• Postpartum depression screening
• Brief emotional behavioral assessment (e.g., depression inventory)
• Screening e.g., developmental milestone survey speech delays
• Instrument e.g., health hazard appraisal or deficit hyperactivity disorder scale

Use this code to support pediatric quality initiatives and other covered preventive services. It is not reported when the patient completes the form; in that case, 96160 should be used.

Common uses of 96161

• Postpartum depression screening during well-baby visits
• Developmental screening in children under 5
• Emotional behavioral assessment e.g., caregiver-reported symptom checklist
• Autism screening or ADHD scale completion by parents
• Reporting postpartum depression screening in new mothers

CPT code 96161 documentation requirements

Proper documentation per standardized instrument is essential. Providers must include:

• The title and type of the health risk assessment instrument used
• The role of the caregiver completing the tool
• A scoring and documentation per clinical standards
• The outcome or interpretation of the responses
• Explanation of how the assessment informed clinical decision-making

This documentation supports reporting recommended screenings and assures accurate diagnosis and treatment planning.

CPT code 96161 billing guidelines

CPT 96161 is billed per health risk assessment instrument completed by the caregiver. Billing and coding must reflect:

• One unit per structured screening instrument
• It may be submitted alongside E/M codes or preventive medicine service codes
• It is not time-based; rather, the emphasis is on scoring and documentation per the tool’s standards
• Verify payer policies as many pediatric quality initiatives bundle this service
• Texas Health Steps pays for this code when requirements are met

Structured screenings and brief assessments, when properly coded and documented, can support preventive benefits and help assure accurate diagnosis in vulnerable populations.

Other relevant CPT codes

• 96160 – Health risk assessment completed by the patient
• 96110 – Developmental screening with standardized tool (e.g., ASQ Screening Tool)

These procedure codes for screening and assessment services cover structured screenings that support comprehensive evaluations.