CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP008

Psychological and Neuropsychological Testing coding and payment

Defines coding, billing, and payment guidance for psychological and neuropsychological testing services provided to Blue Cross and Blue Shield of Oklahoma members; affects providers submitting claims for these services.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPsychological and Neuropsychological Testing coding and payment

Policy CodePolicy CPCP008

Change TypeNo material changes

Effective DateNovember 14, 2024

Next Review DateN/A

Key ActionEstablish medical necessity per PSY 301.020 before performing testing and submit claims only after completion of the entire testing episode.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1.0policy version

Once/yrlimit for testing

16 minmin for 30-min code

31 minmin for per-hour code

~8 hrexpected timeframe

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Coverage criteria and test catalog guidance

Coverage criteria and billing rules

Coverage is contingent on provider qualifications, medical necessity, and appropriate test selection and coding.

Provider must be licensed in state of practice to administer, score, and interpret psychological testing.

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.

Only standardized tests based on published national normative data with scoring that yields standardized or scaled scores qualify for reimbursement.

Claims should be submitted upon completion of all testing-related services for the episode (pre-assessment planning, administration, scoring, integration, report write-up, feedback); if testing spans multiple days submit claim at conclusion of all services.

Time-based CPT codes should not be billed concurrently with other time-based codes for the same service period; base testing codes (96112, 96116, 96130, 96132, 96136, 96138) may be used only once per testing episode.

Comprehensive psychological and neuropsychological assessment codes (96130-96133, 96136-96139) should be used for comprehensive assessments and not for brief screenings or monitoring during routine therapy or follow-up visits; providers should not bill both psychological and neuropsychological evaluation codes for the same episode of service.

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

Catalog guidance

Guidance and constraints present in this excerpt:

Medical necessity as defined by PSY 301.020 must be established prior to testing.

The catalog is an aid and not exhaustive; there may be other covered tests not listed here.

Test Administration and Scoring times were calculated using Tests in Print guidelines and test publisher's guidelines; additional time for Test Evaluation Services will be determined based on tests utilized and accompanying clinical data.

Each test entry includes: 1 = Acronym/Type, 2 = Age (target), 3 = Time (inclusive of administration and scoring).

Coverage prerequisites and notes

Prerequisite for testing

Medical necessity must be established prior to testing per PSY 301.020.

List is illustrative; other covered tests may exist beyond this list.

Test administration and scoring times are provided as guidance; additional time for Test Evaluation Services is determined by tests utilized and accompanying clinical data.

Coverage conditions

Coverage is contingent on established medical necessity per the referenced policy.

Medical necessity must be established prior to testing per PSY 301.020.

This catalog is an aid; other covered tests may exist beyond this list.

Catalog guidance and preconditions

Guidance and constraints noted in this catalog segment:

Medical necessity must be established per PSY 301.020 before testing.

Catalog is an aid; there may be other covered tests not listed.

Test times are estimated from Tests in Print and publisher guidelines; additional time for evaluation services is determined by tests used and accompanying clinical data.

Coverage criteria and notes

This guide lists tests that may be covered but states there may be other covered tests; coverage requires medical necessity per PSY 301.020.

Medical necessity per PSY 301.020 must be established before testing.

Administration and scoring time estimates are provided for each test and may affect service time billing or evaluation service time.

The catalog is an aid and not exhaustive; other covered tests may exist beyond those listed.

CPT codes, timing rules, and examples

Psychological and neuropsychological testing CPT codesCPTCovered

96112	Developmental testing by physician/QHP first hour
96113	Developmental testing each additional 30 minutes
96116	Neurobehavioral status exam by physician/QHP first hour
96121	Neurobehavioral status exam each additional
96130	Psychological test evaluation by physician/QHP first hour
96131	Psychological test evaluation each additional
96132	Neuropsychological test evaluation by physician/QHP first hour
96133	Neuropsychological test evaluation each additional
96136	Test administration by physician/QHP first 30 minutes
96137	Test administration each additional 30 minutes

1–10 of 13

1/2

codes not listedmixed

No CPT/HCPCS/ICD codes provided in this excerpt.

Test timing/catalog entriesmixed

No codes listed

Test catalog entries (no billing codes provided in this segment)mixed

No codes listed

CPT referencemixed

No codes listed

Time minimum for 30-minute code

Minimum time to bill a 30-minute code16 minutes

Time minimum for per-hour codes

Minimum time to bill any per-hour code31 minutes

Base code usage per testing episode

Base code single-use per testing episodeBase codes (96112, 96116, 96130, 96132, 96136, 96138) may only be used once per testing episode; if testing occurs across multiple days, use the base code once at episode start.

Relevant base codes96112, 96116, 96130, 96132, 96136, 96138

PurposePrevents multiple billing of initial/first-hour or first-30-minute base codes within the same testing episode.

Total time example

Example total time for a multi-module batteryNeuropsychological Assessment Battery (all 5 modules) = 3 hours 40 minutes

ContextTime listed is inclusive of administration and scoring as shown in the catalog guidance.

Submission, authorization, and documentation requirements

Prior Authorization

Submit claims after all testing is complete; confirm medical necessity first

Claims must be submitted only after completion of all testing-related services for the episode (including pre-assessment planning, test administration, scoring, integration, report write-up, and feedback); medical necessity must be established prior to testing per PSY 301.020.

Submit claim at conclusion of all services for the testing episode, even if testing occurs across multiple days.
Medical necessity must be established before testing in accordance with PSY 301.020.

Prior Authorization

Establish medical necessity per PSY 301.020 before testing

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

Establish and document medical necessity per PSY 301.020 before beginning testing.

Documentation Required

Medical necessity required prior to testing (PSY 301.020)

Medical necessity must be established prior to testing in accordance with the Psychological and Neuropsychological Testing Policy (PSY 301.020).

Ensure documentation shows medical necessity per PSY 301.020 before test administration.

Prior Authorization

Confirm medical necessity (PSY 301.020) for prior authorization

Medical necessity as defined by PSY 301.020 must be established prior to testing; this requirement applies to prior authorization and documentation for testing services.

Confirm medical necessity per PSY 301.020 when seeking prior authorization or preparing records for review.

Prior Authorization

Prior medical necessity required (PSY 301.020)

Medical necessity must be established prior to testing per the Psychological and Neuropsychological Testing Policy (PSY 301.020).

Do not perform or bill for testing until medical necessity per PSY 301.020 is documented.

Prior Authorization

Establish medical necessity (PSY 301.020) before testing/prior authorization

Medical necessity as defined by the Psychological and Neuropsychological Testing Policy (PSY 301.020) must be established prior to testing; this is required for prior authorization and claims considerations.

Document medical necessity per PSY 301.020 before initiating testing or submitting prior authorization requests.

Terms and test catalog fields

Qualified Healthcare Professional (QHP)

Qualified Healthcare Professional (QHP) definitionQHP must be independently licensed and contracted with the plan; individuals working or training under QHP supervision are considered technicians.

Billing implicationCPT 96130-96133 may only be billed by a QHP meeting these criteria.

Licensure requirementProviders must be licensed in their state of practice to administer, score, and interpret testing.

Comprehensive testing

Definition of comprehensive testingTesting that includes administration, scoring, integration, report write-up and feedback and is not limited to brief inventories or screening tests.

ExclusionBrief symptom inventories or screening tests alone do not qualify as comprehensive testing and should be billed using brief assessment or automated testing CPT codes.

Test entry fields

Test entry fields formatTest entries are presented as: 1 = Acronym/Type, 2 = Age (target), 3 = Time (inclusive of administration and scoring).

PurposeProvides standardized catalog format to show test name, target age, and time estimate inclusive of administration and scoring.

Medical necessity requirement

Medical necessity prerequisiteMedical necessity must be established according to the Psychological and Neuropsychological Testing Policy (PSY 301.020) before testing is performed.

When to establishPrior to testing; failure to establish may subject claims to review or denial.

Time (inclusive of administration and scoring)

Time includes administration and scoringTest administration and scoring times listed are inclusive of both activities and are used to guide billing and evaluation time calculations.

Source of estimatesTimes were calculated using Tests in Print guidelines and test publisher's guidance.

Medical necessity

Medical necessity must be established per referenced policyMedical necessity must be established per PSY 301.020 prior to testing.

Reference policyPsychological and Neuropsychological Testing Policy (PSY 301.020)

Medical necessity (PSY 301.020)

Definition of medical necessityMedical necessity is defined by the Psychological and Neuropsychological Testing Policy (PSY 301.020) and must be established prior to testing.

Coverage consequenceClaims may be subject to medical records and medical necessity review if multiple tests or repeat testing are submitted.

Inclusive time estimate for administration and scoring of a test

Inclusive time estimate meaningTest Administration and Scoring time is the estimated time inclusive of administration and scoring for each test.

Use in billingThese inclusive times inform whether time-based CPT codes meet minimum reporting thresholds (e.g., 16 or 31 minutes).

Administration and Scoring time

Administration and Scoring time definitionEstimated time inclusive of administration and scoring as listed per test in the catalog.

Examples providedCatalog entries list specific time estimates (e.g., Neuropsychological Assessment Battery = 3h 40m; many tests 15–60 minutes).

Medical necessity (pre-testing requirement)

Pre-testing medical necessity requirementMedical necessity must be established per PSY 301.020 prior to testing and before billing for services.

Claims timingClaims should be submitted upon completion of all testing-related services for the episode.

Test administration and scoring times

Source of administration/scoring time calculationsTest administration and scoring times were calculated using established Tests in Print guidelines and test publisher's guidelines.

Operational noteAdditional time for Test Evaluation Services will depend on tests used and accompanying clinical data.

Medical necessity (policy cross-reference)

Medical necessity requirement reiteratedMedical necessity must be established per PSY 301.020 prior to testing.

Policy cross-referenceSee Psychological and Neuropsychological Testing Policy (PSY 301.020) for criteria and process.