Coverage notes for Appendix A and guidance for listed tests. Consolidated operational expectations and usage requirements for Appendix A catalog entries and for billing/testing coverage.
Appendix A is an aid for providers who administer psychological and neuropsychological testing and is not an exhaustive list of covered tests. Medical necessity as defined by the Psychological and Neuropsychological Testing Policy (PSY 301.020) must be established prior to testing. (See chunks: 55, 64, 83)
Approval for payment applies only to standardized tests that are based on published, national normative data with scoring that results in standardized or scaled scores. Providers must document the specific test(s) used, rationale for selection, and how results informed clinical decision-making. (See chunks: 4, 55, 58)
Test administration and scoring times shown in Appendix A are estimates based on Tests in Print and test publisher guidelines; additional time for test interpretation, integration of data, report write-up and feedback is separate and should be reflected in total billed time. Time estimates are inclusive of administration and scoring but do not substitute for clinical documentation describing total service components. (See chunks: 7, 32, 55, 58, 97)
When a listed test is used, the provider must ensure the test version, age range, and administration modality match the member’s clinical needs and the details in Appendix A (age ranges and typical administration times). Appendix A entries include test name, acronym, type, target age, and estimated time; use these as clinical and billing references, not guarantees of coverage. (See chunks: 19, 26, 74, 89, 92)
Psychological and neuropsychological testing is generally limited to once per calendar year. More than one claim submission for testing in a year may be subject to medical record review and medical necessity determination. Exceptions may be made when clinical circumstances justify repeat testing (e.g., significant change in clinical status, pre/post intervention evaluations) and documentation supports medical necessity. (See chunk: 4)
Base CPT codes for psychological and neuropsychological testing (e.g., 96130-96133, 96136-96139) should be used only for comprehensive assessments. Brief symptom inventories, screening tests, or automated brief assessments do not qualify as comprehensive testing and should be billed with appropriate brief assessment codes instead. Providers should not bill comprehensive testing codes for brief screens or routine therapy monitoring. (See chunks: 3, 4, 7, 55)
Time-based CPT codes must reflect actual time spent. A minimum of 16 minutes is required to report a 30-minute code and a minimum of 31 minutes is required to report an hour-based code. Time-based testing codes should not be billed concurrently with other time-based services for the same service period (for example, a therapy session and a time-based testing code for overlapping time). If testing occurs across multiple days, the base code should be used once per testing episode, with supplemental timed units documented as appropriate. (See chunks: 3, 4)
Providers performing comprehensive evaluations must choose whether the evaluation is psychological or neuropsychological and bill accordingly; do not bill both psychological and neuropsychological comprehensive evaluation codes for the same episode of service. (See chunk: 3)
Testing services must be provided or overseen by medical or mental health providers who are licensed in their state 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 and cannot independently bill these QHP-only codes. Documentation should identify the QHP and any technicians involved. (See chunks: 3, 4)
When using Appendix A entries in support of coverage, providers must include in the claim and clinical record: the specific test name and version, administration time, scoring method, standardized score results (when applicable), interpretation linking findings to diagnosis or treatment planning, and rationale for repeat or additional testing if performed within the same calendar year. (See chunks: 7, 55, 58, 97)