Monday, August 6, 2012

cpt codes 96101, 96103, 96111, 96116, 96118- psychological and Neuropsychological Tests CPT codes

Procedure code and description

96101 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g. MMPI, Rorschach®, WAIS®), per hour of the psychologist’s or physician’s time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report. 96101 is also used in those circumstances when additional time is necessary to integrate other sources of clinical data, including previously completed and reported technician– and computer–administered tests. Do not report 96101 for the interpretation and report of 96102, 96103.  average fee payment - $70 - $90

96102 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g. MMPI, and WAIS), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face.

96103 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g. MMPI), administered by a computer, with qualified health care professional interpretation and report.


96111 Developmental testing; extended (includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments) with interpretation and report

These services are primarily performed in the pediatric population after an initial evaluation has demonstrated that further assessment is reasonable and necessary.

A separate interpretation and report should be readily located in the medical record.
These assessments are considered specialized and not routine.

CPT codes 96101 - 96125

Medicare Part B coverage of psychological tests and neuropsychological tests is authorized under section 1861(s)(3) of the Social Security Act. Payment for psychological and neuropsychological tests is authorized under section 1842(b)(2)(A) of the Social Security Act. The payment amounts for the new psychological and neuropsychological tests (CPT codes 96102, 96103, 96119 and 96120) that are effective January 1, 2006, and are billed for tests administered by a technician or a computer reflect a site of service payment differential for the facility and non-facility settings. Additionally, there is no authorization for payment for diagnostic tests when performed on an “incident to” basis.




Psychological Assessment

Psychological assessment is similar to psychological testing but usually involves a more comprehensive assessment of the individual. Psychological assessment is a process that involves the integration of information from multiple sources, such as tests of normal and abnormal personality, tests of ability or intelligence, tests of interests or attitudes, as well as information from personal interviews. Collateral information is also collected about personal, occupational, or medical history, such as from records or from interviews with parents, spouses, teachers, or previous therapists or physicians. A psychological test is one of the sources of data used within the process of assessment; usually more than one test is used. Many psychologists do some level of assessment when providing services to clients or patients, and may use for example, simple check lists to assess some traits or symptoms. Psychological assessment is a complex, detailed, in-depth process. Typical types of focus for psychological assessment provide a diagnosis for treatment settings; assess a particular area of functioning or disability often for school settings; help select type of treatment or assess treatment outcomes; help courts decide issues such as child custody or competency to stand trial; or to help assess job applicants or employees and provide career development counseling or training.

Indications and Limitations of Coverage and/or Medical Necessity

Psychological testing

CPT codes 96101, 96102, 96103, 96105, 96111
Psychological tests are used to assess a variety of mental abilities and attributes, including Central Nervous System (CNS) Assessments such as neuro-cognitive, mental status, achievement and ability, personality, and neurological functioning.

Psychological testing requires a clinically trained examiner. All psychological tests should be administered, scored, and interpreted by a trained professional such as a clinical psychologist, psychologist, advanced nurse practitioner with education in this area or a physician assistant who works with a psychiatrist with expertise in the appropriate area. The purpose of psychological testing includes the following:

To assist with diagnosis and management following clinical evaluation when a mental illness or psychological abnormality is suspected.

To provide a differential diagnosis from a range of neurological/psychological disorders that present with similar constellations of symptoms, e.g., differentiation between pseudodementia and depression.

To determine the clinical and functional significance of a brain abnormality.

To delineate the specific cognitive basis of functional complaints.

Neuropsychological Testing: 

CPT codes 96116, and 96118, 96119 and 96120

These evaluations are requested for patients with a history of psychological, neurologic or medical disorders known to impact cognitive or neurobehavioral functioning. The evaluations include a history of medical or neurological disorders compromising cognitive or behavioral functioning; congenital, genetic, or metabolic disorders known to be associated with impairments in cognitive or brain development; reported impairments in cognitive functioning; and evaluations of cognitive function as a part of the standard of care for treatment selection and treatment outcome evaluations.

CPT Codes for Diagnostic Psychological and Neuropsychological Tests

CPT codes 96101, 96102, 96103, 96105, 96110, and 96111 are appropriate for use when billing for psychological tests. CPT codes 96116, 96118, 96119 and 96120 are appropriate for use when billing for neuropsychological tests. All of the tests under this CPT code range 96101-96120 are indicated as active codes under the physician fee schedule database and are covered if medically necessary.


Standardized Cognitive Performance Testing (CPT code 96125)

Neuropsychological testing (eg., Ross Information Processing Assessment, LOTCA- Loewenstein Occupational Therapy Cognitive Assessment, MVPT - Motor-Free Visual Perception Test, ACL - Allen Cognitive Test), (per hour of the Occupational Therapist's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report.) This is usually done outside the occupational therapy’s initial evaluation/re-evaluation.

Payment and Billing Guidelines for Psychological and Neuropsychological Tests

The technician and computer CPT codes for psychological and neuropsychological tests include practice expense, malpractice expense and professional work relative value units. Accordingly, CPT psychological test code 96101 should not be paid when billed for the same tests or services performed under psychological test codes 96102 or 96103. CPT neuropsychological test
code 96118 should not be paid when billed for the same tests or services performed under neuropsychological test codes 96119 or 96120. However, CPT codes 96101 and 96118 can be paid separately on the rare occasion when billed on the same date of service for different and separate tests from 96102, 96103, 96119 and 96120. Under the physician fee schedule, there is no  ayment for services performed by students or trainees. Accordingly, Medicare does not pay for services represented by CPT  odes 96102 and 96119 when performed by a student or a trainee. However, the presence of a student or a trainee while thetest is being administered does not prevent a physician, CP, IPP, NP, CNS or PA from performing and being paid for the psychological test under 96102 or the neuropsychological test under 96119.



Payment and Billing Guidelines for Psychological and Neuropsychological Tests

 Occupational therapists and speech language pathologists uses CPT code 96125 when they perform test on patients who have compromised functioning abilities due to acute neurological events such as traumatic brain injury or cerebrovascular accident (CVA) and must undergo assessment to determine if function abilities such as orientation, memory and high-level language function have been compromised and to what extent  For psychological and neuropsychological testing by a physician or psychologist, see 96101-96103, 96118-96120.

e. Reading of the report is included in the office time or floor time in the hospital and, is not considered a separate service when performed by the treating provider.

f. CPT code 96101, 96102, 96105, 96110, 96111, 96116, 96118 or 96119, is reported as one unit per hour. If 30 - 1 hr of time is spent performing the test, interpretation and report one unit of time should be billed. If the psychological testing, interpretation and report takes less than 30 minutes, the definition of the CPT code has not been met and the testing may not be billed.
Psychological Tests and Neuropsychological Tests


Medicare Part B coverage of psychological tests and neuropsychological tests is authorized under section 1861(s)(3) of the Social Security Act. Payment for psychological and neuropsychological tests is authorized under section 1842(b)(2)(A) of the Social Security Act. The payment amounts for the new psychological and neuropsychological tests (CPT codes 96102, 96103, 96119 and 96120) that are effective January 1, 2006, and are billed for tests administered by a technician or a computer reflect a site of service payment differential for the facility and non-facility settings. Additionally, there is no authorization for payment for diagnostic tests when performed on an “incident to” basis.

Under the diagnostic tests provision, all diagnostic tests are assigned a certain level of supervision. Generally, regulations governing the diagnostic tests provision require that only physicians can provide the assigned level of supervision for diagnostic tests. However, there is a regulatory exception to the supervision requirement for diagnostic psychological and neuropsychological tests in terms of who can provide the supervision. That is, regulations allow a clinical psychologist (CP) or a physician to perform the general supervision assigned to diagnostic psychological and neuropsychological tests.

In addition, nonphysician practitioners such as nurse practitioners (NPs), clinical nurse specialists (CNSs) and physician assistants (PAs) who personally perform diagnostic psychological and neuropsychological tests are excluded from having to perform these tests under the general supervision of a physician or a CP. Rather, NPs and CNSs must perform such tests under the requirements of their respective benefit instead of the requirements for diagnostic psychological and neuropsychological tests. Accordingly, NPs and CNSs must perform tests in collaboration (as defined under Medicare law at section 1861(aa)(6) of the Act) with a physician. PAs perform tests under the general supervision of a physician as required for services furnished under the PA benefit.

Furthermore, physical therapists (PTs), occupational therapists (OTs) and speech language pathologists (SLPs) are authorized to bill three test codes as “sometimes therapy” codes. Specifically, CPT codes 96105, 96110 and 96111 may be performed by these therapists. However, when PTs, OTs and SLPs perform these three tests, they must be performed under the general supervision of a physician or a CP.



CPT Codes for Diagnostic Psychological and Neuropsychological Tests

The range of CPT codes used to report psychological and neuropsychological tests is 96101-96120. CPT codes 96101, 96102, 96103, 96105, 96110, and 96111 are appropriate for use when billing for psychological tests. CPT codes 96116, 96118, 96119 and 96120 are appropriate for use when billing for neuropsychological tests.

All of the tests under this CPT code range 96101-96120 are indicated as active codes under the physician fee schedule database and are covered if medically necessary.


Coverage Indications, Limitations, and/or Medical Necessity

    Neuropsychological tests provide measurements of brain function that are objective, valid, and reliable. Neuropsychological tests are quantifiable in nature and require patients to directly demonstrate their level of cognitive competence in a particular cognitive domain.

Neuropsychological tests are administered in the context of a comprehensive assessment that synthesizes data from clinical interview, record review, medical history, and behavioral observations. Information from neuropsychological assessments directly impacts medical management of patients by providing information about diagnosis, prognosis, and treatment of disorders that are known to impact central nervous system (CNS) functioning. In addition, neuropsychological assessments predict functional abilities across a variety of disorders.

    Indications for neuropsychological assessments include a history of medical or neurological disorder compromising cognitive or behavioral functioning; congenital, genetic, or metabolic disorders known to be associated with impairments in cognitive or brain development; reported impairments in cognitive functioning; and evaluations of cognitive function as a part of the standard of care for treatment selection and treatment outcome evaluations (e.g., deep brain stimulators, epilepsy surgery). Neuropsychological assessments are not limited in relevance to patients with evidence of structural brain damage, and are frequently necessary to document impairments in patients with probable neuropsychological and neurobehavioral disorders, and are the tool of choice whenever objective documentation of subjective cognitive complaints and symptom validity testing are indicated. In children and adolescents, a significant inability to develop expected knowledge, skills or abilities as required to adapt to new or changing cognitive, social, emotional, or physical demands warrants a neuropsychological evaluation.

    Neuropsychological testing is not supported or excluded from medical necessity based on diagnosis alone. Rather, indications for testing are based on whether there is known or suspected neurocognitive involvement or effects, or where neuropsychological testing will impact the management of the patient by confirmation or delineation of diagnosis, or otherwise providing substantive information regarding diagnosis, treatment planning, prognosis, or quality of life.

    Neuropsychological testing is useful in persons with documented changes in cognitive function to differentiate neurologic diseases (i.e., one of the types of dementia) or injuries (e.g., traumatic brain injury, stroke) from depressive disorders or other psychiatric conditions (e.g., psychosis, schizophrenia) when the diagnosis is uncertain after complete neurological examination, mental status examination, and other neurodiagnostic studies (e.g., CT scanning, MR imaging). The clinician presented with complaints of memory impairment or slowness in thinking in a patient who is depressed or paranoid may be unsure of the possible contribution of neurological changes to the clinical picture. Neuropsychological testing may be particularly helpful when the findings of the neurological examination and ancillary procedures are either negative or equivocal. The differential diagnosis of incipient dementia from depression is a case in point, particularly when computed tomography (CT) fails to yield definitive results.

    Neuropsychological testing may be indicated in persons with epilepsy. Neuropsychological testing is used in these patients to monitor the efficacy and possible cognitive side effects of drug therapy (e.g., new anti-convulsant drug therapy) by comparing baseline performance with subsequent testing performance. Neuropsychological testing is also used to assess post-surgical changes in cognitive functioning to guide further treatment services. Preferably, these tests should be administered by a psychiatrist or certified psychologist trained to conceptualize the neuro-anatomical and the neuro-behavioral implications of the diagnostic entities under consideration and who is capable of interpreting patterns of test scores in view of principles of lateralization and localization of cerebral function.

    Codes 96105, 96111, 96116, 96118, 96119, 96120, and G0451 are defined by their CPT/HCPCS descriptors. Code 96105 represents the formal evaluation of aphasia using a psychometric instrument such as the Boston Diagnostic Aphasia Examination. This testing is typically performed once during treatment, and the medical necessity for such testing should be documented. Repeat testing should only be done if there is a significant change in the patient’s aphasic condition.

    Codes 96118, 96119, and 96120 describe testing which is intended to diagnose and characterize the neurocognitive effects of medical disorders that impinge directly or indirectly on the brain.

    Neuropsychological testing is considered medically necessary for the following indications:

        When there are deficits on standard mental status testing or clinical interview, and a neuropsychological assessment is needed to establish the presence of abnormalities or distinguish them from other disease processes; or

        When neuropsychological data could provide clarification of clinical, laboratory, and neuroimaging data to assist in establishing a clinical diagnosis in neurological or systemic conditions known to affect CNS functioning; or

        When there is a need to quantify cognitive or behavioral deficits related to CNS impairment, and the information will be useful in determining a prognosis or treatment planning by determining the rate of disease progression; or

        When there is a need for a pre-surgical or treatment-related cognitive evaluation to inform whether one might safely proceed with a medical or surgical procedure that may affect brain function (e.g., deep brain stimulation, resection of brain tumors or arteriovenous malformations, epilepsy surgery) or significantly alter a patient’s functional status; or

        When there is a need to assess the potential impact of adverse effects of therapeutic substances that may cause cognitive impairment (e.g., radiation, chemotherapy, antiepileptic medications), and this information is utilized in treatment planning; or

        When there is a need to assess progression, recovery, and response to changing treatments, in patients with CNS disorders, in order to determine the most effective plan of care; or

        When there is a need for objective measurement of patients' subjective complaints about memory, attention, or other cognitive dysfunction, which directly impacts medical management by differentiating psychogenic from neurogenic syndromes (e.g., dementia vs. depression), and in some cases will result in initial detection of neurological disorders or systemic diseases affecting the brain; or

        When there is a need for treatment planning purposes of determining functional abilities/impairments in individuals with known or suspected CNS disorders (e.g., capacity for independent living or movement from a family home into an institutional setting); or

        When there is a need to determine whether a patient can comprehend and participate effectively in complex treatment regimens and to determine functional capacity for health care decision-making, independent living, etc.; or

        When there is a need to design, administer, and/or assess outcomes of cognitive rehabilitation procedures, often in collaboration with other specialists such as speech pathologists, occupational therapists, physiatrists, and rehabilitation psychologists; or

        When there is a need for treatment planning of identification and assessment of neurocognitive sequelae of disease ; or

        Assessment of neurocognitive functions for the formulation of rehabilitation and/or management strategies for certain individuals with neuropsychiatric disorders; or

        When there is a need to diagnose cognitive or functional deficits in children and adolescents based on an inability to develop expected knowledge, skills or abilities as required to adapt to new or changing cognitive, social, emotional, or physical demands.

    The content of neuropsychological testing procedures (96118, 96119, and 96120) differs from that of psychological testing (96101-96111 and G0451) in that neuropsychological testing consists primarily of individually administered ability tests that comprehensively sample cognitive and performance domains that are known to be sensitive to the functional integrity of the brain (e.g., abstraction, memory and learning, attention, language, problem solving, sensorimotor functions, constructional praxis, etc.).

    Neuropsychological testing does not rely on self-report questionnaires such as the Minnesota Multiphasic Personality Inventory 2 (MMPI-2), rating scales such as the Hamilton Depression Rating Scale, or projective techniques such as the Rorschach or Thematic Apperception Test (TAT). In circumstances when additional time is necessary to integrate other sources of clinical data including previously completed and reported technician- and/or computer-administered tests, the neuropsychological testing may include time spent integrating self-report questionnaires.

    Psychological testing codes (96101, 96102, and 96103) include the administration, interpretation, and scoring of the tests mentioned in the procedure descriptors and other medically accepted tests for the evaluation of intellectual strengths, psychopathology, psychodynamics, mental health risks, insight, motivation, and other factors influencing treatment and prognosis.

    Psychological tests are used to address a variety of questions about people’s functioning, diagnostic classification, co-morbidity, and choice of treatment approach. For example, personality tests and inventories evaluate the thoughts, emotions, attitudes, and behavioral traits that contribute to an individual’s interpersonal functioning. The results of these tests determine an individual's personality strengths and weaknesses and may identify certain disturbances in personality or psychopathology. One type of personality test is the projective personality assessment, which asks a subject to interpret some ambiguous stimuli, such as a series of inkblots. The subject's responses can provide insight into his or her thought processes and personality traits.

    Examples of problems that might require psychological testing include:


        1. Assessment of mental functioning for individuals with suspected or known mental disorders for purposes of differential diagnosis and/or treatment planning.
        2. Assessment of patient strengths and disabilities for use in treatment planning or management when signs or symptoms of a mental disorder are present.
        3. Assessment of patient capacity for decision-making when impairment is suspected that would affect patient care or management.
        4. Assessment of mental function in certain chronic pain patients when indicated after psychological screening prior to surgical pain management intervention (e.g., implantable neurostimulator).
        5. Assessment of mental function in a chronic pain patient with suspected somatization disorder.

    Changes in mental illness may require psychological testing to determine new diagnoses or the need for changes in therapeutic measures. Repeat testing not required for diagnosis or continued treatment would be considered medically unnecessary. Nonspecific behaviors that do not indicate the presence of, or change in, a mental illness would not be an acceptable indication for testing. Psychological or psychiatric evaluations that can be accomplished through the clinical interview alone (e.g., response to medication) would not require psychological testing, and such testing might be considered as medically unnecessary. Adjustment reactions or dysphoria associated with moving to a nursing facility do not constitute medical necessity for psychological testing.

    When a psychiatric condition or the presence of dementia has already been diagnosed, there is value to the testing only if the information derived from the testing would be expected to have significant impact on the understanding and treatment of the patient. Examples include a significant change in the patient’s condition, the need to evaluate a patient’s capacity to function in a given situation or environment, and/or the need to specifically tailor therapeutic and/or compensatory techniques to particular aspects of the patient’s pattern of strengths and disabilities.

    Limitations

    Psychological and Neuropsychological testing is not considered reasonable and necessary when:

        the patient is not neurologically and cognitively able to participate in a meaningful way in the testing process;
        administered for educational or vocational purposes that do not establish medical management;
        performed when abnormalities of brain or emotional function are not suspected;
        used for self-administered or self-scored inventories or screening tests of cognitive function (paper-and-pencil or computerized), e.g., AIMS, Folstein Mini-Mental Status Examination;
        Repeated when not required for medical decision-making. Examples of medical decision making include: whether to start or continue a particular rehabilitative or pharmacologic therapy);
        Administered when the patient has a substance abuse background, and any of the following apply: the patient has ongoing substance abuse such that test results would be inaccurate, or the patient is currently intoxicated;
        The patient has been diagnosed previously with brain dysfunction, e.g., Alzheimer’s disease, and there is no expectation that the testing would impact the patient's medical management;
        The test is being given solely as a screening test for Alzheimer's disease. This screening is not covered for this diagnosis.


    Testing conducted when no mental illness/disability is suspected would be considered screening and would not be covered. Non-specific behaviors that do not suggest the possibility of mental illness or disability are not an acceptable indication for testing.

    Evaluations of the mental status that can be performed within the psychiatric diagnostic evaluation (e.g., codes 90791, 90792), (e.g., a list of questions concerning symptoms of depression or organic brain syndrome, corresponding to brief questionnaires or screening measures such as the Folstein Mini Mental Status Examination or the Beck Depression Scale, or use of other mental status exams in isolation ) should not be classified separately as psychological or neuropsychological testing (codes 96101-96120, G0451) since they are typically part of a more general psychiatric/psychological clinical exam or interview.

    Psychological/neuropsychological testing to evaluate adjustment reactions or dysphoria associated with placement in a nursing home does not constitute medical necessity for testing. Testing of every patient upon entry to a nursing home would be considered a routine service and would not be covered. However, some individuals enter a nursing home at a time of physical and cognitive decline and may require psychological/neuropsychological testing to arrive at a diagnosis and plan of care. Decisions to test individuals who have recently entered a nursing home need to be made judiciously, on a case-by-case basis.

    Each psychological/neuropsychological test administered must be individually medically necessary. A standard battery of tests is only medically necessary if each individual test in the battery is medically necessary.

    The psychological/neuropsychological testing codes should not be reported by the treating physician for only reading the testing report or explaining the results to the patient or family. Payment for these services is included in the payment for other services rendered to the patient, such as evaluation and management services. Psychological and neuropsychological testing codes should be reported by the performing provider (i.e., clinical psychologist, neuropsychologist, or physician) who administered the test.


 Group 1 Codes

    96101 Psycho testing by psych/phys
    96102 Psycho testing by technician
    96103 Psycho testing admin by comp
    96105 Assessment of aphasia
    96111 Developmental test extend
    96116 Neurobehavioral status exam
    96118 Neuropsych tst by psych/phys
    96119 Neuropsych testing by tec
    96120 Neuropsych tst admin w/comp
    G0451 Devlopment test interpt&rep


Billing Guide

1. A technician employed and supervised by the primary qualified health care profession who interpretation tests, may perform Central Nervous System Assessments /Tests procedure codes 96102 or 96119. Central Nervous System Assessments/Tests procedure codes 96103 or 96120 may be performed by a computer supervised by the primary provider

2. procedure codes 96102 and 96119 describe tests administered by a technician and the provider’s time for the interpretation and the report of each individual test and the report of each individual test result. The integration of all the test data determines the cognitive profile. The provider’s time for interpretation of the test is billed under procedure code used to
bill the test.

3. procedure codes 96103 and 96120 describe computer tests and the provider’s time for the interpretation and the report. No time is billed for these codes.

4. Per Medicare regulations Central Nervous System Assessments/Tests procedure codes 96101- 96125 may not be reimbursed to clinical social workers.

5. Physical therapists (PTs), occupational therapists (OTs) and speech language pathologists (SLPs) are authorized to bill procedure codes 96105, and 96111 as “sometimes therapy” services, services that follow the rules for Physical/Occupational/speech language pathologists. However, when PTs, OTs and SLPs administer these tests, they must be under the general supervision of a physician or clinical psychologists.
6. procedure code 96125 has been established to report tests performed by speech-language pathologists and occupational therapists. When the test is performed by other Medicare providers, they should not use procedure code 96125 but rather, the appropriate procedure codes 96101-96103 or 96118-96120 should be used.

7. To bill these services to Medicare the practitioner providing the testing must have a Medicare provider number and be appropriately licensed in the State where the services are performed. 

procedure Codes for Diagnostic Psychological and Neuropsychological Tests

The range of procedure codes used to report psychological and neuropsychological tests is 96101- 96120. procedure codes 96101, 96102, 96103, 96105, and 96111 are appropriate for use when billing for psychological tests. procedure codes 96116, 96118, 96119 and  96120 are appropriate for use when billing for neuropsychological tests.

All of the tests under this procedure code range 96101-96120 are indicated as active codes under the physician fee schedule database and are covered if medically necessary. 

Payment and Billing Guidelines for Psychological and Neuropsychological Tests

The technician and computer procedure codes for psychological and neuropsychological tests include practice expense, malpractice expense and professional work relative value units. Accordingly, procedure psychological test code 96101 should not be paid when billed for the same tests or services performed under psychological test codes 96102 or 96103. procedure neuropsychological test code 96118 should not be paid when billed for the same tests or services performed under neuropsychological test codes 96119 or 96120. However, procedure codes 96101 and 96118 can be paid separately on the rare occasion when billed on the same date of service for different and separate tests from 96102, 96103, 96119 and 96120.

Under the physician fee schedule, there is no payment for services performed by students or trainees. Accordingly, Medicare does not pay for services represented by procedure codes 96102 and 96119 when performed by a student or a trainee. However, the presence of a student or a trainee while the test is being administered does not prevent a physician, CP, IPP, NP, CNS or PA from performing and being paid for the psychological test under 96102 or the neuropsychological test under 96119 .http://www.cms.gov/manuals/Downloads/bp102c15.pdf 


ICD-10 Codes that Support Medical Necessity
    
    For CPT/HCPCS codes 96101, 96102, 96103, 96118, 96119, 96120,and G0451 only:

    Group 1 Codes

    F01.50 Vascular dementia without behavioral disturbance

    F01.51 Vascular dementia with behavioral disturbance

    F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance

    F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance

    F03.90 Unspecified dementia without behavioral disturbance

    F03.91 Unspecified dementia with behavioral disturbance

    F04 Amnestic disorder due to known physiological condition

    F05 Delirium due to known physiological condition

    F06.0 Psychotic disorder with hallucinations due to known physiological condition

    F06.1 Catatonic disorder due to known physiological condition

    F06.2 Psychotic disorder with delusions due to known physiological condition


    F06.30 Mood disorder due to known physiological condition, unspecified

    F06.31 Mood disorder due to known physiological condition with depressive features

    F06.32 Mood disorder due to known physiological condition with major depressive-like episode

    F06.33 Mood disorder due to known physiological condition with manic features

    F06.34 Mood disorder due to known physiological condition with mixed features

    F06.4 Anxiety disorder due to known physiological condition

    F06.8 Other specified mental disorders due to known physiological condition

    F07.0 Personality change due to known physiological condition

    F07.81 Postconcussional syndrome

    F07.89 Other personality and behavioral disorders due to known physiological condition


CAUTION – What You Need to Know

The Centers for Medicare & Medicaid Services (CMS) announces the revision of the CPT codes for psychological and neuropsychological tests (codes 96101 through 96120) to include tests performed by technicians and computers (CPT codes 96102, 96103, 96119 and 96120) in addition to those performed by physicians, clinical psychologists, independently practicing psychologists and other qualified non-physician practitioners (as described in Background, below).



Medicare Part B coverage of psychological tests and neuropsychological tests is authorized under section 1861(s)(3) of the Social Security Act, and payment for these tests is authorized under section 1842(b)(2)(A) of the Social Security Act.

The CPT codes for these tests are included in the range of codes from 96101 to 96120.

The appropriate codes when billing for psychological tests are: 96101, 96102, 96103, 96105, 96110, and 9611; and when billing for neuropsychological tests are: 96116, 96118, 96119 and 96120. All of the tests under this CPT code range 96101-96120 are covered and indicated as active codes under the MPFS database.

More specifically, CR 5204, from which this article is taken, provides that (effective January 1, 2006) the CPT codes for psychological and neuropsychological tests include tests performed by technicians and computers (CPT codes 96102, 96103, 96119 and 96120) in addition to tests performed by physicians, clinical psychologists, independently practicing psychologists and other qualified nonphysician practitioners.

These changes, made in accordance with the final physician fee schedule regulation, were published in the Federal Register on November 21, 2005, at 70 FR 70279 and 70280 under Table 29 (AMA, Relative Value Update Committee (RUC) and Health Care
Professional Advisory Committee (HCPAC) Recommendations and CMS Decisions for New and Revised 2006 CPT Codes).

You should be aware of some supervision requirements for diagnostic psychological and neuropsychological tests. First, under the diagnostic tests provision, all diagnostic tests are assigned a certain level of supervision. Generally, regulations governing the diagnostic tests provision allow only physicians to provide the assigned level of supervision for such tests; however, for diagnostic psychological and neuropsychological tests, there is a regulatory exception that allows either a clinical psychologist (CP) or a physician to perform the assigned general supervision.

Billing Guide for procedure code 96110 and 96111

The rate structure for these codes for EarlySteps is different from the old rate for 92506 and is explained below, beginning on page 3.

In EarlySteps, the 92506 code was used for single-domain assessments, eligibility and exit evaluations and autism screenings. Since the code was discontinued, the replacement codes for evaluations and screenings are:

• 96110 Eligibility and Exit (Outcome Measures) evaluations

• 96111 Autism screenings



The rates for these evaluation and screening codes have not changed. The 96110 and 96111 code changes occur in the Central Finance Office (CFO) Rate and Service Schedule only, since Medicaid does not reimburse for these two codes for EarlySteps.

The following information addresses some of the most commonly asked questions about the new evaluation codes and what changes will occur within EarlySteps.



What Early Steps services are affected by the elimination of 92506?

• Rate changes and the 4 newly identified codes only apply to single domain assessments conducted by SLPs in EarlySteps.

• For SLPs who conduct eligibility and exit evaluations using the BDI2, the 92506 code will be replaced by 96111—the rates remain the same. This will be revised in the CFO service schedule and authorizations in July 2014. No changes in rates.

• For SLPs, who conduct autism screenings, the 92506 code will be replaced by 96110—the rates remain the same. This will be revised in the CFO service schedule and authorizations in July 2014. No changes in rates.

• Medicaid does not reimburse for eligibility or exit evaluations or autism screenings, so there is no impact for billing through Molina for SLP evaluators for these. The only change for Medicaid claims is for the 4 new codes for single domain assessments.



What is the reimbursement rate for each code?

The Centers for Medicare and Medicaid Services (CMS) has established the 2014 national rates for speechlanguage pathology codes under the Medicare Physician Fee Schedule (MPFS). EarlySteps developed the rate schedule based on our rate structure which includes a varied rate according to the code area and the setting where the assessment occurred. The rate schedule is shown in the chart below. The codes for 96110 and 96111 are the same rate as the old 92506 for these procedures.

Covered Services

Items and services that can be included as part of the structured, multimodal active treatment program, include:
Individual or group psychotherapy with physicians, psychologists, or other mental health professionals authorized or licensed by the State in which they practice (e.g., licensed clinical social workers, clinical nurse specialists, certified alcohol and drug counselors);
Occupational therapy requiring the skills of a qualified occupational therapist. Occupational therapy, if required, must be a component of the physicians treatment plan for the individual;
Services of other staff (social workers, psychiatric nurses, and others) trained to work with psychiatric patients;
Drugs and biologicals that cannot be self administered and are furnished for therapeutic purposes (subject to limitations specified in 42 CFR 410.29);
Individualized activity therapies that are not primarily recreational or diversionary. These activities must be individualized and essential for the treatment of the patient’s diagnosed condition and for progress toward treatment goals;
Family counseling services for which the primary purpose is the treatment of the patient’s condition;
Patient training and education, to the extent the training and educational activities are closely and clearly related to the individuals care and treatment of his/her diagnosed psychiatric condition; and
Medically necessary diagnostic services related to mental health treatment.

Limitations

Noncovered Services-Benefit category Denials
Day care programs, which provide primarily social, recreational, or diversionary activities, custodial or respite care;
Programs attempting to maintain psychiatric wellness, where there is no risk of relapse or hospitalization, e.g., day care programs for the chronically mentally ill; or
Patients who are otherwise psychiatrically stable or require medication management only.
Noncovered Services-Coverage Denials
Services to hospital inpatients;
Meals, self-administered medications, transportation; and
Vocational training.
Noncovered-Reasonable and Necessary Denials
Patients who cannot, or refuse, to participate (due to their behavioral or cognitive status) with active treatment of their mental disorder (except for a brief admission necessary for diagnostic purposes), or who cannot tolerate the intensity of a PHP; or
Treatment of chronic conditions without acute exacerbation of symptoms that place the individual at risk of relapse or hospitalization.
CPT codes 90875 and 90876

Billing Guide from UHC

Psychological Testing (CPT Codes 96101, 96102, 96103)

Any of the following criteria must be met….

1. A clinical evaluation was inconclusive and additional information which can be derived from psychological testing is needed to establish the member’s behavioral health diagnosis. Examples include but are not limited to:

a. The member presents with symptoms that could be indicative of more than one behavioral health condition, and a differential diagnosis could not be made.

b. The member presents with atypical symptoms.

2. A clinical evaluation was inconclusive and additional information which can be derived from psychological testing is needed to inform the treatment plan. Examples include, but are not limited to:

a. Outstanding questions about the member’s level of functioning must be answered in order to gauge the member’s capacity to participate in behavioral health treatment.

b. Outstanding questions about a change in the member’s presenting symptoms must be answered in order to gauge the adequacy of the treatment plan.

c. There are outstanding questions about why a member’s response to treatment has not been as expected.

https://www.bcbsri.com/sites/default/files/polices/PsychologicalandNeuropsychologicalTesting.pdf

The following two services, in the aggregate, are limited to 6 hours (units) of testing per provider/group per calendar year. Services greater than 6 hours will be denied as not separately reimbursed:

96101
96102

The following three services, in the aggregate, will be limited to 10 hours ( units) of testing per provider/group per calendar year. Services greater than 10 hours will be denied as not separately reimbursed:

96116
96118
96119

The following interview codes are covered and can be filed on the same dates of services as the above codes and do not apply to the Neurological/psychological reimbursement limits described above.

90801
90802

The following testing codes are covered and do not apply to the psychological/neuropsychological testing limits described above.

96103

Coding:

The following codes are covered under the member's diagnostic imaging, lab, and machine test benefit:

96101
96102
96116
96118
96119

The following therapy codes will be considered not separately reimbursed IF provided on the same date as 96101, 96102, 96116, 96118, or 96119:

90804
90805
90806
90807
90808
90809
90810
90811
90812
90813
90814
90815
90823
90824
90826
90827

The following codes are covered as medical services and not impacted by this policy:

96105
96110
96111 (this code is limited to specialties noted above)

Q: Does BCBSRI allow claims with CPTcodes 96101 and 96118 on the same date of service by the same provider?

A: Yes

Q: Can I perform psychological testing and psychotherapy on the same date of service?

A: No, the following therapy codes will be considered not separately reimbursed if provided on the same date of service as 96101, 96102, 96116, 96118, or 96119: 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90823, 90824, 90826, 90827.

Q: What are the claims submission guidelines when a patient completes a test administered by the computer for part of the testing session, and the remainder of the session is spent with the psychologist?

A: You should always follow CPT guidelines. Presently, it would be appropriate to submit a claim for the computer test and a 96101 or 96118, provided that the actual time spent with the psychologist met the CPT guideline “per hour of the psychologist’s time.” You cannot factor time spent on the computer test into the 96101 or 96118 for that day. For example, if a patient spent 15 minutes completing a computer test and then spent only 45 minutes with the psychologist, it would not be appropriate to submit a claim for 96101 or 96118 for the 15 minutes spent on computer testing. Additionally, any time spent interpreting the test should not be reported using 96101 or 98118. These two services represent interview and testing by the physician or psychologist and the time spent integrating multiple test results into a report

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