CurrentBlue Cross Blue Shield - New MexicoPolicy CPCP008

Psychological and Neuropsychological Testing

Clarifies BCBSNM payment and coding rules for covered psychological and neuropsychological testing services and guidance for providers submitting claims; affects providers billing BCBSNM for these testing services.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPsychological and Neuropsychological Testing

Policy CodePolicy CPCP008

Change TypeAnnual review (no material changes)

Effective DateNov 16, 2023

Next Review DateNov 16, 2024

Key ActionEstablish and document medical necessity per PSY 301.020 before performing and billing psychological or neuropsychological testing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Once/yeartesting frequency limitation

16min minutes for 30‑min code

31min minutes for hourly code

≈8 hrsneuropsych eval timeframe

3–4 hrsprocedure readiness testing

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COVERAGE CRITERIA — coverage is for medically necessary psychological and neuropsychological testing when performed/overseen by appropriately licensed providers; includes conditional rules and references to PSY 301.020

Coverage is provided for medically necessary psychological and neuropsychological testing when performed or overseen by appropriately licensed providers. The Appendix A catalog is an aid for providers; tests not listed may still be covered if medical necessity is established per PSY 301.020. The following criteria and guidance summarize provider obligations, billing rules, and limits.

ALL of the following

Testing services must be provided or overseen by medical or mental health providers who are licensed in their state of practice to administer, score and interpret psychological testing.
Providers working or training under supervision are considered technicians; certain codes (96130-96133) may only be billed by an independently licensed Qualified Healthcare Professional (QHP) who is contracted with the plan (see guidelines).
Claims should be submitted upon completion of all testing-related services for the testing episode, including pre-assessment planning, test administration, scoring, integration of data, report write-up, and feedback. If testing occurs across multiple days, submit the claim at the conclusion of the episode.
Base testing codes (96112, 96116, 96130, 96132, 96136, 96138) may be used only once per testing episode; if testing spans multiple days, the base code is reported once at the start of the episode.
Approval for payment applies only to standardized tests based on published, national normative data with scoring that yields standardized or scaled scores.
Computerized or automated tests follow same medical necessity standard; see references for position statements on computerized assessment.
Testing comprised solely of brief symptom inventories or screening tests does not qualify as comprehensive psychological testing; when indicated, bill using brief assessment or automated testing CPT codes rather than comprehensive testing codes.
CPT codes 96130-96133, 96136-96139 should be reserved for comprehensive assessments and not used for brief screenings or routine therapy progress monitoring unless a comprehensive assessment is performed.
CPT codes that are time-based should not be billed concurrently with other time-based codes for the same service period. For example, a 60-minute therapy session that includes a brief inventory should not also include a separate 30- or 60-minute testing code for overlapping time.
Providers may bill a therapy code and a brief behavioral assessment code when a brief inventory is administered during therapy, but must not bill additional time-based testing codes exceeding the actual time spent.
Testing is generally limited to once per calendar year; more than one testing claim in a year may be subject to medical records and medical necessity review.
Exceptions may exist if medically necessary and documented per PSY 301.020.
Expected timeframes are provided as guidelines and represent typical total time for administration, scoring, interpretation and report write-up: neuropsychological evaluations ~8 hours; psychological testing for medical procedure readiness (e.g., bariatric surgery) ~3–4 hours; testing to diagnose uncomplicated ADHD ~3–4 hours (neuropsychological testing for ADHD indicated when there is notable medical or neurological history).
A minimum of 16 minutes is required to report a 30-minute code; a minimum of 31 minutes is required to report any per-hour code.

Coverage Criteria and Appendix Guidance

Appendix A is a catalog of psychological and neuropsychological tests intended as a provider aid. Inclusion in the catalog does not by itself establish coverage; medical necessity per PSY 301.020 must be documented prior to testing. Test administration and scoring times are estimates (inclusive of administration and scoring) based on Tests in Print and publisher guidelines; additional time for test evaluation services will depend on tests used and clinical data.

ALL of the following

The catalog lists commonly used tests with estimated administration and scoring times and typical age ranges; there may be other covered tests not listed.
Providers should reference the catalog to plan testing episodes but must document medical necessity for each test performed.
Test administration and scoring times in the catalog are estimates; report actual time-based codes consistent with CPT time thresholds and the plan's billing guidelines.
A minimum of 16 minutes is required to report a 30-minute code; 31 minutes for per-hour codes.
Coverage of a specific test requires that the test is standardized with published normative data and yields standardized or scaled scores when required for the CPT code billed.

Codes, Timing, and Administration Rules

Psychological and neuropsychological testing CPT codesCPTCovered

96105	Assessment of aphasia
96110	Developmental screening with score
96112	Developmental testing by physician/QHP first hour
96113	Each additional hour (developmental testing)
96116	Neurobehavioral status exam by physician/QHP first hour
96121	Neurobehavioral status exam each additional hour
96127	Brief emotional/behavioral assessment
96130	Psychological test evaluation by physician/QHP first hour
96131	Each additional hour (psychological test evaluation)
96132	Neuropsych test evaluation by physician/QHP first hour

1–10 of 16

1/2

Not listed in this excerptmixed

No codes listed

Test list (acronyms and names)mixed

No codes listed

Coding referenceCPT

CPT (see 2022/2023 editions)

Reference to Current Procedural Terminology as coding source

inv-12: Minimum minutes for 30-min code

Minimum required minutes16 minutes must be provided to report a 30-minute code.

Source contextListed under policy guidelines for CPT time thresholds.

Implication for billingDo not report a 30-minute time-based CPT code unless at least 16 minutes of relevant service were provided.

inv-13: Minimum minutes for hourly codes

Minimum required minutes31 minutes must be provided to report any per-hour code.

Source contextListed under policy guidelines for CPT time thresholds.

Implication for billingDo not report an hourly time-based CPT code unless at least 31 minutes of relevant service were provided.

inv-14: Base code usage per testing episode

Base codes limited per episodeBase testing codes (96112, 96116, 96130, 96132, 96136, 96138) may be used only once per testing episode.

Timing when testing spans daysIf testing takes place across multiple days, the base code should only be used once at the start of the service episode.

Billing implicationSubmit claims upon completion of all testing related services for the episode; do not re-use base code for subsequent days within same episode.

inv-15: Administration and scoring time guidance

Primary time sourcesAdministration and scoring times were calculated using Tests in Print and test publisher guidelines.

Additional Test Evaluation Services timeAdditional time for Test Evaluation Services will be determined based on tests utilized and accompanying clinical data.

Catalog usePer-test times listed in the catalog are inclusive of administration and scoring and are estimates to guide billing and scheduling.

Documentation, Prior Authorization, and Medical Necessity

Documentation Required

Documentation and claim review

Providers are responsible for submission of accurate documentation of services performed and must use valid HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC, DRG, etc.). Claims are subject to code edit protocols and review for benefit coverage, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. Upon request, providers should submit additional documentation to support services billed.

Submit claims using industry-standard coding guidelines (CPT®, HCPCS, ICD-10, DRG, NDC).
Claims may be reviewed and audited; additional documentation may be requested.

Prior Authorization

Medical necessity and frequency review

CPT codes 96130-96133 may only be billed by a Qualified Healthcare Professional (QHP) who is independently licensed and contracted with the plan; individuals working or training under supervision are considered technicians. Psychological and neuropsychological testing must be standardized with published normative data and scoring producing standardized or scaled scores. Testing is generally limited to once per calendar year; multiple submissions may trigger medical necessity review. Time-reporting minimums apply (e.g., 16 minutes for a 30-minute code; 31 minutes minimum to report any per-hour code).

CPT 96130-96133: billable only by independently licensed, contracted QHPs.
Testing limited to once per calendar year; >1 claim/year may be subject to medical necessity review.
Minimum time rules: 16 minutes for 30-minute code; 31+ minutes for hourly codes.

Prior Authorization

Medical necessity requirement

Medical necessity must be established prior to testing as defined by the Psychological and Neuropsychological Testing Policy (PSY 301.020). Test administration and scoring times were calculated using Tests in Print and publisher guidelines; additional time for evaluation services depends on tests used and accompanying clinical data. Expected timeframes (examples): neuropsychological evaluations ≈ 8 hours; testing for medical-procedure readiness ≈ 3–4 hours; psychological testing for uncomplicated ADHD ≈ 3–4 hours. Providers should ensure medical necessity documentation is available upon request.

Establish medical necessity per PSY 301.020 before testing.
Test times based on Tests in Print and publisher guidelines; additional evaluation time varies by test and clinical data.
Example expected timeframes: Neuropsychological evaluation ≈ 8 hours; procedure-readiness testing 3–4 hours; ADHD testing 3–4 hours.

Prior Authorization

Prior authorization / medical necessity

Prior authorization and medical necessity: medical necessity per PSY 301.020 must be established prior to testing; providers should obtain any required authorizations per member plan documents and provider contract terms.

Obtain prior authorization when required by the member’s plan.
Document medical necessity per PSY 301.020 before performing tests.

Note

References and coding source

References and coding sources: professional guidelines and coding references should be used to inform clinical practice and billing. Relevant sources include the American Psychiatric Association Practice Guideline for the Psychiatric Evaluation of Adults; Tests in Print (Buros Institute); American Psychological Association Billing and Coding Guide (2019) and its Addendum; APA guidelines for test user qualifications; AACN practice guidelines; ASMBAS recommendations for presurgical psychosocial evaluation; and literature on computerized neuropsychological assessment devices. Providers should follow CPT/HCPCS/ICD-10 and other industry coding guidance when billing.

Key references: APA Practice Guideline for Psychiatric Evaluation (2015); Tests in Print; APA 2019 Psychological and Neuropsychological Testing Billing and Coding Guide and Addendum; APA test user qualifications summary; AACN Practice Guidelines; ASMBAS presurgical psychosocial evaluation recommendations.
Follow CPT/HCPCS/ICD-10, AMA CPT guidance, CMS NCCI/CCI edits, UB editor, and other standard coding resources when submitting claims.

Definitions and Catalog Field Guide

inv-24: testing episode

DefinitionTesting episode — the complete sequence of testing-related services (pre-assessment planning, test administration, scoring, integration of data, report write-up and feedback) billed upon conclusion of all services.

Claim timingIf testing takes place across multiple days, submit the claim at the conclusion of all services for the episode.

Base code useBase testing codes are limited to a single use within a testing episode.

inv-25: QHP (independently licensed and contracted professional authorized to bill certain testing codes)

DefinitionQualified Healthcare Professional (QHP) — an independently licensed and contracted professional authorized to bill CPT codes 96130–96133 (and related codes) under the plan.

Technician relationshipIndividuals working or training under the supervision of a QHP are considered technicians and do not independently bill those QHP-only codes.

Billing restrictionCPT codes 96130–96133 may only be billed by a QHP who is independently licensed and contracted with the plan.

inv-26: technician

DefinitionTechnician — an individual working or training under the supervision of a QHP who may perform test administration but is not authorized to bill QHP-only codes.

Billing implicationTest administration by technicians is reported with technician-specific codes (e.g., 96138/96139) while QHPs report first-hour test administration/evaluation codes.

Supervision noteQHPs must oversee technicians; supervision requirements affect which codes can be billed by which provider type.

inv-27: Test entry fields

Fields provided per test entryEach test line provides: Test Name (and common acronyms), the construct/type, age range, and approximate time inclusive of administration and scoring.

Catalog columnsTest Name, 1 = Acronym; Test Name, 2 = Type or Age; Test Name, 3 = Time (inclusive of administration and scoring).

PurposeThe catalog is an aid to estimate administration/scoring duration and applicable ages; presence on the list is not a coverage guarantee without medical necessity.

inv-28: Test administration and scoring times

DefinitionTest administration and scoring times — listed durations are inclusive of administration and scoring and are estimates used for billing and scheduling.

Calculation sourceTimes were calculated using Tests in Print and test publisher guidelines.

Catalog guidancePer-test times in the appendix reflect these calculated estimates but may vary by clinical circumstances and additional required testing.

inv-29: Medical necessity

RequirementMedical necessity must be established prior to testing as defined by the Psychological and Neuropsychological Testing Policy (PSY 301.020).

Frequency reviewTesting is limited to once per calendar year; more than one claim may prompt medical records and medical necessity review.

Coverage preconditionPresence of a test in the catalog does not guarantee coverage without meeting medical necessity requirements.

inv-30: Test administration/scoring time calculation method

Calculation methodTest administration/scoring times were calculated using Tests in Print and test publisher guidelines.

Additional time for Test Evaluation ServicesAdditional time for Test Evaluation Services will be determined based on tests utilized and accompanying clinical data.

Use in catalogListed per-test times are provided as inclusive estimates (administration + scoring) to guide billing decisions.

inv-31: Medical necessity requirement

Pre-test requirementMedical necessity as defined by PSY 301.020 must be established prior to testing; this is a condition of coverage.

Claims implicationClaims submitted without demonstrated medical necessity may be subject to review or denial.

Reference policyProviders should reference the Psychological and Neuropsychological Testing Policy (PSY 301.020) for detailed medical necessity criteria.

inv-32: Catalog column definitions

Catalog column definitionsTest Name, 1 = Acronym; Test Name, 2 = Type or Age; Test Name, 3 = Time (inclusive of administration and scoring).

UseColumns standardize how each test entry reports acronym, intended population/type or age, and estimated time (administration + scoring).

Provider noteProviders should use these columns to interpret catalog entries when planning and billing testing services.

inv-33: Scope/limitations

Purpose of guideThe catalog is intended as an aid for providers; it is not exhaustive and other covered tests may exist.

Coverage preconditionInclusion in the catalog does not supersede the requirement that medical necessity per PSY 301.020 be established prior to testing.

Operational notePer-test times are estimates; additional time for Test Evaluation Services may be required depending on tests used and clinical data.

inv-34: Test Administration and Scoring time

DefinitionTest Administration and Scoring time — the listed time for each test is inclusive of administration and scoring and was calculated using Tests in Print and test publisher guidelines.

Estimates onlyListed times are estimates to guide billing and scheduling; actual time may vary based on clinical circumstances.

Additional evaluation timeAdditional time for comprehensive Test Evaluation Services will be determined based on the specific tests used and accompanying clinical data.

inv-35: Medical necessity

Medical necessity preconditionMedical necessity as defined by PSY 301.020 must be established prior to testing; this is required for coverage.

Annual limitationTesting is limited to once per calendar year; multiple submissions may prompt medical necessity review.

ReferenceSee Psychological and Neuropsychological Testing Policy (PSY 301.020) for detailed criteria.

inv-36: References

Primary referencesTests in Print (Buros Institute) and relevant APA and AACN guidelines cited as sources for test selection, timing and qualifications.

Coding referenceCurrent Procedural Terminology (CPT) editions referenced for procedure coding guidance (see AMA CPT 2022/2023).

Practice guidanceProfessional practice guidelines and billing/coding guides (APA) are listed to inform provider responsibilities and testing standards.