Psychological Testing
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Defines medical necessity, coverage limits, coding, and prior authorization rules for psychological, neurobehavioral, and neuropsychological testing across Baylor Scott & White Health Plan lines of business.
Added CPT codes 96132, 96133, and 96121 to covered CPT codes.
Clarified that coverage of CPT 96138/96139/96146 is line-of-business dependent (Medicare vs Medicaid/commercial).
Added Federal MHPAEA mandate discussion.
Consolidated and clarified additional-hours authorization language for testing beyond 6 hours.
Coverage Criteria
Medical necessity criteria
BSWHP may consider psychological testing medically necessary when ALL of the following are met:
Time limits and additional-hours authorization
Standard authorization rules and exceptions:
Medicaid has special rules per TMPPM
Prior authorization required per LOB rules; inpatient testing is exempt from PA
Medicaid limits
Medicaid-specific limits (per TMPPM):
Certain CPT codes (e.g., 96138/96139/96146) have line-of-business dependent coverage; prior authorization required for hours beyond limits per TMPPM
Not medically necessary
Testing is NOT medically necessary in the following circumstances:
See policy 137 for exceptions
See policy 206
Repeat testing
Repeat testing within 12 months is NOT medically necessary unless ALL of the following are documented:
Covered with criteria
Psychological and neuropsychological testing are covered when provided by an allowed provider and meet payer/TMPPM limits and prior authorization requirements.
Refer to TMPPM and payer LOB guidance for provider eligibility and LOB-dependent coverage.
Services that are primarily educational or intended to improve academic or work performance are excluded from coverage. IQ tests, achievement tests, and educational tests are considered educational and are NOT covered benefits for most plans. Services arising from employment-related injuries or court-ordered evaluations are excluded when no documentation of medical necessity is provided.
Psychological testing performed for uncomplicated school-related ADHD evaluations, or testing intended chiefly for educational planning or training, is considered noncovered because it is not focused on direct medical, psychiatric, or psychological treatment needs.
Testing performed while a member is actively abusing substances, in acute withdrawal, or in recent recovery is generally not considered medically necessary because results may be invalid and therefore are excluded.
Prior authorization is not required for testing performed in the inpatient setting. TMPPM guidance specifies that psychological or neuropsychological testing requires prior authorization for services rendered outside the inpatient setting only under specified conditions.
Specifically, prior authorization is required for outpatient testing when a member has exceeded the 30 encounter/visit annual limitation, or when testing will exceed 4 hours in a day or 8 hours in a calendar year.
The policy explicitly states that IQ tests, achievement tests, and educational tests are considered educational and are NOT covered benefits for most plans. Such testing is excluded because it is primarily educational rather than directed at medical or psychiatric treatment needs.
Examples include routine school-based ADHD assessments for members in school, which the policy deems primarily educational and therefore not medically necessary for coverage under most plans.
When testing is court-ordered or connected to employment without documentation of medical necessity, coverage is also excluded unless clear medical necessity is demonstrated in the member's record.
This document was updated to add CPT codes 96132, 96133, and 96121 to the covered CPT code list and to clarify that coverage for CPTs 96138, 96139, and 96146 is dependent on line of business. The policy also incorporated the Mental Health Parity and Addiction Equity Act (MHPAEA) reference and updated background guidance to include neuropsychological evaluation recommendations and APA 2020 guidance.
Additional operational clarifications consolidate the requirements for authorization of testing beyond standard hours, and the internal BUROS test tables were moved to an internal appendix and TMPPM code references were updated.
Providers should follow the updated coding, prior authorization, and documentation requirements in this policy and in applicable TMPPM guidance when seeking authorization or submitting claims.
Coding and Billing Codes
| 96130 | Psychological testing evaluation services by physician or other qualified health care professional; first hour |
| 96131 | Each additional hour (List separately in addition to code for primary procedure) |
| 96116 | Neurobehavioral status exam |
| 96121 | Each additional hour (List separately in addition to code for primary procedure) |
| 96136 | Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional; first 30 minutes |
| 96137 | Each additional 30 minutes (List separately in addition to code for primary procedure) |
| 96132 | Neuropsychological testing evaluation services by physician or other qualified health care professional; first hour |
| 96133 | Each additional hour (List separately in addition to code for primary procedure) |
| 96138 | Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; first 30 minutes |
| 96139 | Each additional 30 minutes (List separately in addition to code for primary procedure) |
| 96138 | Psychological or neuropsychological test administration and scoring by technician [NOT covered for Medicaid; covered for Medicare] |
| 96139 | Each additional 30 minutes [NOT covered for Medicaid; covered for Medicare] |
| 96146 | Psychological or neuropsychological test administration via electronic platform [NOT covered for Medicaid; covered for Medicare] |
| F70-F79 | Intellectual difficulties (listed under ICD10 Not covered) |
| F80.1-F98.9 | Developmental & emotional disorders, ASD (listed under ICD10 Not covered) |
| R53.81-R53.83 | Fatigue & malaise (listed under ICD10 Not covered) |
| Z13.850 | Encounter for screening for traumatic brain injury (listed under ICD10 Not covered) |
| 96130 | Psychological testing evaluation services (per TMPPM listing) |
| 96131 | Psychological testing by technician (per TMPPM listing) |
| 96132 | Neuropsychological testing evaluation (added to covered CPT codes) |
| 96133 | Neuropsychological testing by technician (added to covered CPT codes) |
| 96136 | Psychological or neuropsychological test administration (per TMPPM listing) |
| 96137 | Psychological or neuropsychological test administration (per TMPPM listing) |
| 96138 | Psychological or neuropsychological test scoring and interpretation (LOB-dependent coverage noted) |
| 96139 | Psychological or neuropsychological test scoring and interpretation (LOB-dependent coverage noted) |
| 96146 | Assessment of change in cognitive function (LOB-dependent coverage noted) |
| 96121 | Assessment measure administration added to covered CPT codes |
Provider Actions and Prior Authorization
Prior authorization varies by line of business
Prior authorization requirements vary by line of business: Medicaid lines may require prior authorization per TMPPM; commercial plans require prior authorization when more than 6 hours are requested; Medicare-linked plans do not require prior authorization. Verify the member's plan EOC/SPD and TMPPM guidance for Medicaid requests.
- Medicaid: prior authorization may be required — check TMPPM.
- Commercial: prior authorization required if > 6 hours requested.
- Medicare-linked plans: prior authorization not required.
PA required when TMPPM thresholds exceeded
Per TMPPM, prior authorization is required for outpatient psychological or neuropsychological testing performed outside the inpatient setting when the member has exceeded TMPPM limits (after the 30 encounter annual limit) or when testing exceeds four hours in a day or eight hours in a calendar year.
- Prior authorization required for services rendered outside inpatient setting when: after the 30 encounter/visit annual limitation has been met; or >4 hours testing per day; or >8 hours testing per calendar year.
Step therapy not required
No step therapy requirements are specified in this policy.
Reserved
(No content provided in source for this item.)
Document clinical question, rationale, and impact
Providers must document the specific clinical question(s) the tests will answer, why diagnostic assessment and/or behavioral observation cannot answer those question(s), and how results will impact patient management. Repeat testing requests must include documentation identifying the clinical change necessitating retest (e.g., new neurological event, significant medication change, or clinical deterioration).
- Document the specific clinical question(s) motivating testing.
- Explain why diagnostic assessment/behavioral observations are insufficient.
- Describe how test results will affect clinical management.
- For repeat testing within 12 months, document the change that necessitates retest (examples provided).
Documentation required to support PA for duration/encounters
When requesting prior authorization for testing duration or encounters beyond standard allowances, include documentation supporting medical necessity for hours per day and annual hours and evidence that the 30-encounter annual limit has been exceeded when applicable.
- For >6 hours (commercial) or additional Medicaid hours, submit detailed justification listing each test, allotted time per test, diagnostic purpose, and medical/psychological rationale.
- Document that the 30-encounter annual limit has been exceeded when relying on TMPPM-based PA.
- Include evidence supporting need for more than 4 hours/day or 8 hours/year (Medicaid thresholds).
Common triggers for denial
Requests are at risk for denial when testing is primarily educational (e.g., IQ, achievement, or educational tests), court-ordered without documentation of medical necessity, performed during active substance abuse/acute withdrawal/recent recovery, repeat testing within 12 months without documented change, or when testing exceeds standard allowed hours without detailed justification.
- Educational testing (IQ, achievement, educational) is generally excluded and may be denied.
- Court-ordered testing without clinical justification may be denied.
- Testing during active substance abuse, acute withdrawal, or recent recovery is a denial trigger.
- Repeat testing within 12 months without documented qualifying change may be denied.
- Requests for hours beyond standard limits without the required detailed clinical justification risk denial.
TMPPM prior authorization conditions for outpatient testing
Per TMPPM, prior authorization is required for psychological or neuropsychological testing performed in any place of service except inpatient when: (1) the 30 encounter/visit annual limitation has been met; or (2) more than four hours of testing per day, or more than eight hours of testing per calendar year, are medically necessary.
- Applies to testing delivered outside the inpatient setting.
- Triggers for PA: after 30 encounters/year; >4 hours/day; >8 hours/calendar year.
Background and Context
Psychological and neuropsychological testing assess cognitive, emotional, personality, and functional domains to inform diagnosis, treatment planning, and assessment of functional capacity. Neuropsychological evaluations are recommended when detailed characterization of cognitive functioning is needed and should not be substituted by brief cognitive screens.
Tests should be administered, scored, and interpreted by appropriately qualified clinicians (for example, licensed psychologists or psychiatrists with relevant expertise) in accordance with APA guidance, and results must be used to directly inform the member's medical or behavioral health management.
Definitions
Treatment Modalities
General psychological testing
Tests are one element of assessment and should not be the sole basis for diagnosis; detailed clinical interview and record review required
Psychological/Neuropsychological Testing
From TMPPM 6.11; prior authorization required outside the inpatient setting under TMPPM conditions
Visit and Hours Limits
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