Psychological and Neuropsychological Testing reimbursement
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This policy governs prior authorization, medical necessity criteria, limitations, billing and payment rules for outpatient psychological and neuropsychological testing for University Health Alliance members and providers.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Medical necessity criteria
Testing is covered when medically necessary and all of the following requirements and documentation are met:
ALL of the following
ALL of the following
- PA request must come from a licensed behavioral health care provider or a neurologist; the servicing provider must be a psychologist or neuropsychologist clinically trained to administer, score, and interpret testing
- Patient must have a face-to-face diagnosis of a psychiatric illness by a licensed mental health provider or a neurological disorder by a neurologist; symptoms must meet DSM criteria or, if not, testing is expected to clarify the diagnosis
- A psychiatric diagnostic evaluation (PDE: 90791/90792) or a neurobehavioral status exam (NSE: 96116) must be completed prior to the testing request and must include mental status exam, complete patient history, review of psychological, medical, educational and other relevant records with the patient present
- Documentation must include clinically descriptive behavior, impact on daily functioning, and rationale for testing; brief rating scales or symptom inventories (e.g., GAD-7, PHQ-9) should be completed prior to PA submission and accompany the request
ALL of the following
ANY of the following
- The PDE is inconclusive or clinical symptoms do not meet current DSM diagnostic criteria and testing is expected to clarify diagnosis
- Further evaluation is needed to develop treatment recommendations after trials of medications and/or psychotherapy when the patient remains symptomatic without clear explanation for treatment failure
- Results are expected to have a timely effect on the individual’s treatment plan
Coding, Time Limits, and Reimbursement Rules
| 96130 | Psychological testing evaluation services by physician or other qualified healthcare professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member or caregiver, when performed; first hour. |
| 96131 | Psychological testing evaluation services by physician or other qualified healthcare professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member or caregiver, when performed; each additional hour. |
| 96132 | Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour. |
| 96133 | Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report and interactive feedback to the patient, family member(s) or caregiver(s), when performed; each additional hour. |
| 96136 | Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; first 30. |
| 96137 | Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; each additional 30 minutes (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 | Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; each additional 30 minutes. |
| 96146 | Psychological or neuropsychological test administration, with single automated instrument via electronic platform, with automated result only. |
| 90791 | Psychiatric diagnostic evaluation. |
Prior Authorization, Submission and Payment Actions
Prior authorization required; submit PA form via UHA portal
Prior authorization is required for all outpatient psychological and neuropsychological testing. Complete and submit the PA form specific to psychological and neuropsychological testing via UHA's online provider portal; if you do not have a portal login, contact UHA at 808-532-4000 to establish one. PA requests must come from a licensed behavioral health care provider or neurologist and the testing must be performed by a qualified psychologist or neuropsychologist. Note: diagnostic codes 90791, 90792, and 96116 do not require prior authorization.
- Submit the PA form through UHA's online provider portal (or call 808-532-4000 to establish access) [[see citations]].
- Requests must originate from a licensed behavioral health provider or neurologist; servicing provider must be a qualified psychologist/neuropsychologist.
- Codes 90791, 90792, and 96116 are listed as not requiring prior authorization.
Payment based on minimum testing hours; prebariatric screening limits and PA exception
Payment is calculated based on the minimum number of testing hours required to establish a diagnosis and begin a plan of care. Pre-surgical (prebariatric) psychological clearance screening is limited to 3 hours using CPT 96130/96131/96136/96137 (one unit each); prebariatric psych testing performed by an in‑network psychologist associated directly with a par bariatric program does not require prior authorization when requested units match this limitation.
- Payment is based on minimum testing hours required to establish diagnosis and plan of care.
- Pre-surgical prebariatric screening limited to 3 hours: CPTs 96130, 96131, 96136, 96137 (one unit each).
- Prebariatric psych testing by a UHA par psychologist associated with a par bariatric program is exempt from prior authorization when units requested conform to the 3-hour limit.
- Report generation reimbursement is limited to 1 hour; bill correct codes and units for evaluation vs test administration/scoring (technician/computer codes where applicable).
Key Definitions and Abbreviations
Outpatient Testing Level-of-Care Criteria
Diagnostic Psychological Testing Modalities
Visit Time Limits and Report Reimbursement
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