Understanding the Impact of Coding Changes on Psychological and Neurological Testing
New codes for psychological and neurological testing services since 2019 provide clarification of non-face-to-face work by professionals. The codes have been enhanced with additional details for both the base and add-on codes, offering greater specificity in describing the work performed. This can provide insight into analyzing coding utilization for possible excessive behavior through Fraud Scope.
Background
The American Psychological Association (“APA”) defines psychological tests as any psychometrically derived measurement instrument that assesses the psychological constructs in which a structured sample of an examinee’s behavior in a specified domain is obtained and subsequently quantified, scored, interpreted, and synthesized using a standardized process for the purpose of evaluative conclusion or recommendation.
Psychological and neurological testing, assessment, and evaluation is a core component of psychological practice, treatment planning, and subsequent decisions. Like other medical tests, psychological testing and its results play a crucial role in shaping and refining treatment plans.
In many cases, qualified practitioners who administer tests will then treat patients with psychotherapy. Some qualified practitioners focus only on evaluating patients and then refer them to other specialists for treatment after they’ve made a diagnosis. In either case, the testing and assessment process will ensure that the patient receives treatment that’s tailored to his or her individual needs.
Coding Changes
Since 2019, the coding for psychological testing transitioned from a single comprehensive code to multiple codes. This transition now includes each part of the service from initial assessment to the treatment plan to the final evaluation all being coded separately. Specifically related to psychological and neurological testing, there were 12 codes added to this subsection that allows for the reporting of services provided during testing of the psychological/neuropsychological services.
This change reflects the complexity and time spent on each part of the process. This approach represents more detail and provides a clearer picture of the services offered.
Overall, the update of psychological and neuropsychological testing codes reflected a systematic effort to improve the billing framework, benefiting practitioners and patients by ensuring that assessments are both accurately documented and reimbursed.
According to the Center for Medicare Services (“CMS”), typical testing requires 4-8 hours to perform, including administration and scoring. A minimum of 31 minutes must be provided to report any per hour code. If the testing is performed over several days, the time for all testing should be combined and reported on the last day of service.
How Fraud Scope Can Assist
Indicators of potential waste in psychological testing services may include the overuse of testing without clear clinical indication, redundancy of tests assessing similar domains, or inadequate integration of test results into treatment planning. It is the recommendation of CMS and the APA that if testing services span over multiple days, to combine and submit on the last date of service. This can complicate medical record reviews when considering the business model of practitioners and should be incorporated into reviews for excessive time purported.
Codoxo’s Fraud Scope Platform can assist health plans with identifying cumulative hours for any provider that exceed the expected times for psychological testing that could occur over the course of several days. Most importantly, Fraud Scope can easily identify the cumulative hours for a provider that are impossible over the course of a week, month, or year.
Fraud Scope’s pattern-based detection models, such as Suspicious Trends, Time Behavior, Frequent Combinations, or Outlier Abuse can assist to identify outlier utilization, such as:
- Providers utilizing excessive number of services compared to their peers
- Providers utilizing excessive number of units compared to their peers
- Providers with a high-volume of base and add-on codes for psychological testing
- Identification of moving trends for specific testing services compared to peers
Additional tools within the Fraud Scope suite can be Query Aggregates and Association Analysis.
- Identifying providers whose claim composition and utilization is higher than peers by service
- Association analysis of outgoing and incoming referrals to understand treatment of the following services
Coding Reference
Neurobehavioral Status Exam
| CPT Code | Base Code/ Add-on | Description |
|---|---|---|
| 96116 | Base Code | Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; first hour |
| 96121 | Add-On | Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; each additional hour (List separately in addition to code for primary procedure) |
Test Evaluation Services
| CPT Code | Base Code / Add-on | Description |
|---|---|---|
| 96130 | Base Code | Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour |
| 96131 | Add-On | Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; each additional hour (List separately in addition to code for primary procedure) |
| 96132 | Base Code | Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour |
| 96133 | Add-On | Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; each additional hour (List separately in addition to code for primary procedure) |
Test Administration and Scoring
| CPT Code | Base Code / Add-on | Description |
|---|---|---|
| 96136 | Base Code | Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; first 30 minutes |
| 96137 | Add-On | Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; each additional 30 minutes (List separately in addition to code for primary procedure) |
| 96138 | Base Code | Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; first 30 minutes |
| 96139 | Add-On | Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; each additional 30 minutes (List separately in addition to code for primary procedure) |
References:
CMS: Billing and Coding: Psychological and Neuropsychological Testing
Article – Billing and Coding: Psychological and Neuropsychological Testing (A57481)
APA Guidelines for Psychological Assessment and Evaluation
https://www.apa.org/about/policy/guidelines-psychological-assessment-evaluation.pdf
APA: Understanding psychological testing and assessment
https://www.apa.org/topics/testing-assessment-measurement/understanding
APA: What Insurers Need To Know about New Psychological and Neurological Testing Codes
https://www.apaservices.org/practice/reimbursement/health-codes/testing/webinar-slides.pdf