Psychological and Neuropsychological Testing reimbursement
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Governs reimbursement rules for psychological and neuropsychological testing claims submitted to Healthfirst of New York for identified lines of business; affects all providers and facilities submitting such claims on or after the effective date.
Added multiple sclerosis–related ICD-10 codes (G35.A, G35.B0, G35.B2, G35.C0, G35.C2, G35.D) to the Diagnosis Code Requirements.
Updated Line of Business to include the Medicare-only LOB.
Reimbursement and Coverage Criteria
Reimbursement criteria
Claims for psychological and neuropsychological testing are reimbursable only when submitted with an approved diagnosis code supported by documentation; claims missing such codes will be denied.
ALL of the following
- Approved diagnosis code: Claims must be submitted with an approved ICD-10-CM diagnosis code (examples include: G30–G30.9; F10.11–F19; F01–F09; F30–F39; F20–F29; G35.A; G35.B0; G35.B2; G35.C0; G35.C2; G35.D).
- Claims submitted without an approved diagnosis code will not be eligible for reimbursement and will be denied.
ALL of the following
- Documentation: All documentation must be maintained in the patient’s medical record and made available upon request.
- The submitted medical record must support the use of the selected ICD-10-CM code(s).
- The submitted CPT/HCPCS code must describe the service performed.
- Claim submission: All claims must be submitted electronically or via the appropriate billing format and include the relevant diagnosis code.
Diagnosis and Procedure Codes
| G30-G30.9 | Alzheimer's disease |
| F10.11-F19 | Mental and behavioral disorders due to psychoactive substance use |
| F01-F09 | Mental disorders due to known physiological conditions |
| F30-F39 | Mood (affective) disorders |
| F20-F29 | Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders |
| G35.A,G35.B0,G35.B2,G35.C0,G35.C2,G35.D | Multiple sclerosis–related codes (relapsing-readmitting; primary progressive unspecified; non-active primary progressive; secondary progressive unspecified; non-active secondary progressive; unspecified) |
| 96130 | Psychological testing evaluation services; first hour |
| 96131 | Psychological testing evaluation services; each additional hour |
| 96132 | Neuropsychological testing evaluation services; first hour |
| 96133 | Neuropsychological testing evaluation services; each additional hour |
| 96136 | Test administration and scoring by professional; first 30 minutes |
| 96137 | Test administration and scoring by professional; each additional 30 minutes |
| 96138 | Test administration and scoring by technician; first 30 minutes |
| 96139 | Test administration and scoring by technician; each additional 30 minutes |
| G0451 | Development testing with interpretation and report |
Provider Billing and Documentation Actions
Diagnosis requirement and claim submission
Submit claims with an approved diagnosis code on the claim; claims submitted without an approved diagnosis code will not be eligible for reimbursement and will be denied. All claims must be submitted electronically or via the appropriate billing format and include the relevant diagnosis code.
- Include an approved ICD-10-CM diagnosis code that supports the service on every claim.
- Submit claims electronically or via the appropriate billing format per Healthfirst requirements.
Maintain supporting medical record documentation
Maintain all supporting documentation in the patient's medical record to support the selected ICD-10-CM code(s) and the CPT/HCPCS code billed; the documentation must be made available upon request.
- Medical record must support the use of the selected ICD-10-CM code(s).
- Submitted CPT/HCPCS code must accurately describe the service performed.
- Records must be produced to Healthfirst upon request.
Adjudication, denials, and appeals
Reimbursement is determined by the provider’s scope of work and the provider contract with Healthfirst; claims that do not adhere to this policy will be denied or rejected and are subject to timely filing requirements and appeal processes per the provider contract and Healthfirst Provider Manual.
- Providers are responsible for accurate coding; non-adherent claims may be denied or rejected.
- Final payment depends on benefits, mandates, medical necessity, and provider contract terms.
- Claims are subject to timely filing requirements and the appeals/reconsideration process outlined in the Healthfirst Provider Manual (Subsection 17).
Definitions
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