Psychological Testing Criteria and Codes

Psychological Testing

Background: Psychological testing is an ancillary measurement of behavior and involves the assessment of aptitude, achievement, cognition, personality, interests, emotions, attitudes, and behavioral traits.  These tests and assessments are shown to be reliable and valid in the measurement of emotional, behavioral, and cognitive process, and intellectual abilities.

Psychological testing will be reviewed against the following criteria:

  • Psychological testing is being administered by a qualified provider such as a psychologist or psychiatrist.
  • Patient’s cognitive or emotional concerns require characterization.
  • A clinical question is formulated, addressing why psychological testing is needed. It will either determine a diagnosis or assist with treatment or rehabilitation; and can address the medical, neurologic, psychiatric evaluation, diagnostic testing, or observations in therapy that other assessments cannot.
  • Other testing such as diagnostic, medical, neurologic, mental status, and psychiatric examinations have been completed.
  • Psychological testing is appropriate given the following:  All must apply.
    • Information received from psychological testing is not reached by other modalities such as routine medical, neurologic, or psychological assessments.
    • Psychological testing is appropriate for the underlying behavioral disorder and will support the symptoms identified, behaviors or functional impairment.
    • The patient can participate in psychological testing and it is achievable based on their developmental level, mental status, intellectual, cognitive abilities, and/or language skills.
    • Psychiatric, substance use disorders, and comorbid medical needs are met by collaborating with other providers involved in patient’s care and support systems such as family caregivers, as well as others who are affected by the patient’s behaviors.
    • The amount of time requested for psychological testing is appropriate for testing (8 hours or fewer) and supports testing implementation and scoring.
    • Frequency of testing fits within the norm: one initial testing evaluation followed by one additional re-testing evaluation within 12-month period.

In addition, 2 units of psychological testing (any combination of codes 96130, 96131, 9613, 96136 96137, 96138 or 96139) may be provided without prior authorization per lifetime, per member.

For Washington State-designated Autism Centers of Excellence (COE), up to 7 units of testing (96130, 96131, 96136, 96137, 96138, or 96139) may be provided for a child age 20 or younger suspected of having autism spectrum disorder. These evaluations must be billed using UC modifier and EPA #870001315.

Neuropsychological Testing

Background: Neuropsychological Testing is a comprehensive assessment of cognitive processes to aid in the evaluation of neurological or neurodevelopmental disorders, and in understanding the etiology and evolution of a disorder. To understand cognitive strengths and weaknesses, neuropsychological testing evaluates: attention and concentration, verbal and visual memory, auditory and visual processing, visual-spatial functioning, language and reading skills, sensory development and sensory integration, gross and fine motor development, social skill development, and executive functioning.

Indications/Criteria for Patients Age 21 and Older

  • A PA request for neuropsychological testing of adults, and of children who are not in school, requires all of the following information:
  • The client’s current diagnoses
  • Copies of psychological testing and other assessments already completed
  • Documentation of the provider’s review of reports produced by the testing
  • An explanation detailing the essential medical knowledge that is expected to be gained from psychological testing
  • Specific details documenting how the results of psychological testing will improve the day-to-day care of this client
  • Client is not involved in active substance use, in withdrawal, or in recovery from recent chronic use (should be abstinent for at least one month)

Neuropsychological testing can be considered medically necessary for the following two groups of patients

Rehabilitation patients. All of the following must be met:

  • The patient to be evaluated has, or is suspected to have, an acquired injury to the brain as a result of traumatic brain injury, stroke, multiple sclerosis, aneurysm, anoxia, hypoxia, dementia, neoplasm, or chemotherapy.
  • The patient is age 20 or older.
  • The patient was functioning normally (was able to attend school, work competitively, or live independently) prior to the brain disorder.
  • The patient has potential to return to important areas of role functioning (e.g., work, school, or independent living).
  • Testing will be used only in conjunction with functionally based rehabilitation, not “cognitive” rehabilitation.

Peri-operative assessment

  • The client is undergoing brain surgery for epilepsy, a tumor, or Parkinson’s disease, and neuropsychological testing may help with either of the following:
  • Guide the surgeon in the goal of sparing healthy brain tissue and sites that are critical to some major function such as language
  • Identify poor candidates for neurological surgery due to dementia (e.g., in cases where deep brain stimulation implants are being considered to manage intractable tumors)

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