Rules, Procedures & Guidelines for Psychological Testing
96118-Neuropsychological Testing is considered medically necessary when:
When there are mild or questionable 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 changes that may occur with normal aging, or the expected progression of other disease processes; or
When neuropsychological data can be combined with 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, especially when the information will be useful in determining a prognosis or informing 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 determine 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, stem cell transplant) 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), especially when this information is utilized to determine treatment planning; or
When there is a need to monitor progression, recovery, and response to changing treatments, in patients with CNS disorders, in order to establish the most effective plan of care; or
When there is a need for objective measurement of the patient’s subjective complaints about memory, attention, or other cognitive dysfunction, which serves to determine treatment by differentiating psychogenic from neurogenic syndromes (e.g., dementia vs. depression); or
When there is a need to establish a treatment plan by determining functional abilities/impairments in individuals with known or suspected CNS disorders; or
When there is a need to determine whether a patient can comprehend and participate effectively in complex treatment regimens (e.g., surgeries to modify facial appearance, hearing, or tongue debulking in craniofacial or Down syndrome patients; transplant or bariatric surgeries in patients with diminished capacity), and to determine functional capacity for health care decision-making, work, independent living, managing financial affairs, etc.; or
When there is a need to design, administer, and/or monitor outcomes of cognitive rehabilitation procedures, such as compensatory memory training for brain-injured patients; or
When there is a need to establish treatment planning through identification and assessment of the neurocognitive sequelae of systemic disease (e.g., hepatic encephalopathy; anoxic/hypoxic injury associated with cardiac procedures); or
Assessment of neurocognitive functions for the formulation of rehabilitation and/or management strategies among 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.
Examples of problems that might lead to neuropsychological testing include:
Detection of neurologic diseases based on quantitative assessment of neurocognitive abilities (e.g., mild head injury, anoxic injuries, AIDS dementia);
Differential diagnosis between psychogenic and neurogenic syndromes;
Delineation of the neurocognitive effects of CNS disorders;
Neurocognitive monitoring of recovery or progression of CNS disorders; and/or
Assessment of neurocognitive functions for the formulation of rehabilitation and/or management strategies among individuals with neuropsychiatric disorders.
Determining the management of the patient by confirmation or delineation of diagnosis.
Components of the Neuropsychological Evaluation
Record Review
The provider reviews the medical records and referral question, and determines whether an evaluation is appropriate.
Neuropsychological tests include direct question-and-answer, object manipulation, inspection and responses to pictures or patterns, paper-and-pencil written or multiple choice tests, which measure functional impairment and abilities in:
a. General intellect
b. Reasoning, sequencing, problem-solving, and executive function
c. Attention and concentration
d. Learning and memory
e. Language and communication
f. Visual-spatial cognition and visual-motor praxis
g. Motor and sensory function
h. Mood, conduct, personality, quality of life
i. Adaptive behavior (Activities of Daily Living)
j. Social-emotional awareness and responsivity
k. Psychopathology (e.g., psychotic thinking or somatization)
l. Motivation and effort (e.g., symptom validity testing)
96118 & 96119, 96101 & 96102 What is Considered Billable Time
The time component is not defined or addressed by Medicare so billing should be done in 1 hour increments. If testing, interpreting results, reporting, takes more than one-half hour, then one unit of the appropriate code should be billed. If testing, interpreting results, reporting takes more than one and one-half hour, then two units of the procedure code should be billed.
While the MCI Screen and Depression Screen are easily administered within minutes, the effort required to prepare for the patient’s visit and to counsel the patient should also be considered. Such considerations could include but are not limited to Physician time spent:
• Pulling a patient’s record (E&M)
• Familiarizing themselves with the clinical decision making process that led them to be tested (E&M)
• Meeting with the patient to remind them of the reason for the test and prepare them to be tested (E&M)
• Reviewing the results of the assessment, analyzing and interpreting the report (E&M)
• Developing a plan of care (Interpretation)
• Meeting with the patient, discussing the results and recommending a plan of care (E&M)
96116-Neurobehavioral Status Exam
is defined in the CPT manual as ‘neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist’s or physician’s time, both face to face time with the member and time interpreting test results and preparing the report.’
We are implementing a new reimbursement policy that follows the CPT guidance restricting billable use of this code to psychologists and/or physicians. In addition, there will be a limit of 5 hours/units per year, to help ensure the code is being used consistently. Instances of services exceeding 5 hours/units per year are subject to review for case-specific detail This February 2014 Connecticut 14 of 20 policy applies to all commercial Anthem health plans. (Please note that Medicaid and Medicare plans may have additional regulation and other guidance about utilization.)
Assessment prior to Neuropsychological Evaluation
According to the CMS “A neurobehavioral status exam is completed prior to the administration of neuropsychological testing. The status exam involves clinical assessment of the patient, collateral interviews (as appropriate and review of prior records. The interview would involved clinical assessment of several domains including but limited to; thinking, reasoning and judgment, e.g., acquired knowledge, attention, language, memory, planning and problem solving and visual spatial abilities. The clinical assessment would determine the types of tests and how those tests should be administered.”
6. CPT code 96116 may be utilized by a neuropsychologist in lieu of 90791 to bill for an initial neuropsychological assessment visit, and may be utilized to bill for a 1 hour neurocognitive evaluation.
What modifiers are valid when billed with Healthcare Common Procedure Coding System (HCPCS) code 96116? Effective January 1, 2008, the following modifiers are valid when billed with HCPCS code 96116: • GT – Via interactive audio and video telecommunications system
96119 & 96102 Technician (psychometrist) Billing
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 CPT 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. Ref.
Can Psychological testing and Psychotherapy be done on the Same Date?
No.
