Billing Guide for Psychological Screening and Testing ...

[Pages:7]Billing Guide for Psychological Screening and Testing - 2022

Quick Reference

Type

Performed Code Conditions Minimum Allowable Telemed Audio

By

Time

Usable

Only

Screening

Any

96127

1-2

NA

$4.80

Permanent

Yes

Test

Provider 96136

2+

16 Minutes $45.44 Through 2023 Yes

Administration

Test

Technician 96138

2+

16 Minutes $36.05 Through 2023 Yes

Administration

Test Evaluation Provider 96130

1+

31 Minutes $122.53 Through 2023 Yes

Screening

Mental Health screening is the attempt to detect mental health symptoms in a large number of apparently healthy individuals. This can be done in many different ways from paper-based instruments in the exam room, to computer-based screening in the waiting room, to physician interviews during a routine exam. The goal is to evenly apply the screening process to as many patients as possible in order to identify the largest number of individuals suffering from mental health issues.

Screening Codes

Code: CPT 96127 Note:

ICD10 codes:

CMS Definition:

Recommended Fee Schedule:

Brief emotional/behavioral assessment with scoring and Average Medicare allowable of: $4.80

documentation, per standardized instrument.

Recommended charge of: $20

Most insurances allow the 96127 CPT code to be billed up to 4 times per year with up to 2 Units. Make sure if multiple screenings are run, CPT code 96127 is on the CMS form only 1 time. The additional screenings are added to the units section of the CMS line; 1 unit for each assessment. Most insurance, including medicare, will not allow the use of 96127 in addition to CPT 96130 96146.

Medicare: Medicare requires the use of G0444 rather than 96127 if screening during the annual wellness visit, and should be justified with the annual wellness ICD-10 code. 96127 may be used for screening at any other time. Major Medical: Most insurance companies require the generic screening ICD-10 code Z13.89

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Test Administration

Once the potential for a mental health condition has been established by either screening or the presence of a comorbid condition, testing is used to determine the presence or absence of that mental health condition. For the purpose of billing, test administration requires "medical necessity" and must be justified by a related ICD-10 code. Test administration can be performed by either a physician or qualified healthcare professional, or a technician under the supervision of a physician or qualified healthcare professional, using the method allowed for each code.

Test Administration Codes

Code type: CPT 96136

CPT 96138

CPT 96146 ICD10 codes

CMS Definition:

Recommended Fee Schedule:

Psychological or neuropsychological test administration Average Medicare allowable of: $45.44

and scoring by physician or other qualified healthcare

Recommended charge of: $110

professional, two or more tests, any method, first 30

minutes.

Note: For each additional 30 minutes use CPT code 96137.

Psychological or neuropsychological test administration Average Medicare allowable of: $36.05

and scoring by technician, two or more tests, any

Recommended charge of: $90

method; first 30 minutes.

Note: For each additional 30 minutes use CPT code 96139.

Psychological or neuropsychological test administration, Average Medicare allowable of: $1.96

with single automated instrument via electronic platform, Recommended charge of: $10

with automated result only.

Medicare: Medicare requires mental health related ICD10 codes (codes beginning in F) or codes for

conditions/ symptoms comorbid to mental health conditions - refer to the latest Medicare Billing

and Coding Articles for the exact covered codes.

Major Medical: Depending on the specific coverage for mental health in a patient's plan there are 2

approaches to choosing ICD-10 codes.

1. If the billing provider is a behavioral health provider and/ or the plan covers mental health,

then bill using mental health related ICD10 codes (codes beginning in F).

2. If the billing provider is NOT a behavioral health provider and/ or the plan does not cover

mental health, bill using ICD10 codes for conditions/ symptoms comorbid to mental health.

For example, depression and anxiety are comorbid to diabetes, and it is the standard of care

to test for both when treating diabetes. The ICD10 code for diabetes should justify the

administration in most circumstances.

Note to Non-behavioral health providers: Most commercial insurance companies separate their

behavioral health claims. If the mental health tests were used to determine whether or not mental

health was affecting the physical health of the patient, the claim should be processed by the

physical medicine side. ICD10 codes related to physical medicine can avoid the complexities

generated by behavioral health coverage.

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Test Evaluation Services

Test evaluation services are designed to cover the physician or qualified healthcare professional's time in evaluating the results of a patient's mental health tests and determining a plan of action.

Test Evaluation Codes

Code type: CPT 96130

ICD10 codes:

CMS Definition:

Recommended Fee Schedule:

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(s) or caregiver(s), when performed; first hour Note: For each additional one-hour use CPT code 96131.

Average Medicare allowable of: $122.53 Recommended charge of: $275

Medicare: Medicare requires mental health related ICD10 codes (codes beginning in F) or codes for conditions/ symptoms comorbid to mental health conditions - refer to the latest Medicare Billing and Coding Articles for the exact covered codes. Major Medical: Depending on the specific coverage for mental health in a patient's plan there are 2 approaches to choosing ICD-10 codes.

1. If the billing provider is a behavioral health provider and/ or the plan covers mental health, then bill using mental health related ICD10 codes (codes beginning in F).

2. If the billing provider is NOT a behavioral health provider and/ or the plan does not cover mental health, bill using ICD10 codes for conditions/ symptoms comorbid to mental health. For example, depression and anxiety are comorbid to diabetes, and it is the standard of care to test for both when treating diabetes. The ICD10 code for diabetes should justify the administration in most circumstances.

Note to Non-behavioral health providers: Most commercial insurance companies separate their behavioral health claims. If the mental health tests were used to determine whether or not mental health was affecting the physical health of the patient, the claim should be processed by the physical medicine side. ICD10 codes related to physical medicine can avoid the complexities generated by behavioral health coverage.

Additional Billable Codes

Additional billable services are available below that cover codes for Medicare and Medicaid annual wellness visits, and annual substance use counseling.

G0442 Medicare H0049 Medicaid

G codes for Medicare

Alcohol and/or substance use (other than tobacco) screening and brief intervention services, between 15-30 minutes Note: May use up to once per year

G0444 (96127)

Average Medicare allowable of: $18 Recommended charge of: $50

See 96127 Above

ICD10 codes: Use the ICD10 code for the annual wellness visit.

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NCCI Guidelines

NCCI - 2021

The psychiatric diagnostic interview examination (CPT codes 90791, 90792), psychological/ neuropsychological testing (CPT codes 96136-96146), and psychological/ neuropsychological evaluation services (CPT codes 96130-96133) must be distinct services if reported on the same date of service. "CPT Manual" instructions permit physicians to integrate other sources of clinical data into the report that is generated for CPT codes 96130-96133. Since the procedures described by CPT codes 96130-96139 are timed procedures, physicians shall not report time for duplicating information (collection or interpretation) included in the psychiatric diagnostic interview examination and/or psychological/ neuropsychological evaluation services or test administration and scoring. (CPT codes 96101 and 96118 were deleted January 1, 2019.)

Additional Notes: 96127 should not be billed with 96130, 96136, 96138, or 96146 96136 OR 96138 can be billed with 96130 as long as the time for each service is counted separately If time is used to calculate your E&M then it must be separate from the time spent for either 96130, 96136, or 96138 When determining if time was met for a timed code, you must have at least 1/2 of the code time plus 1 minute. For example a 30 minute code like 96136 or 96138 would require at least 16 minutes of total time administering a test, confirming answers, etc. in order to count.

Psychiatrists Only: You cannot bill 90792 along with 96130, 96136, or 96138, as they are essentially for the same services. You can bill an E&M code along with 96130, 96136, and/ or 96138. (Depending on the situation it may make more sense to use an E&M along with a 96130 and a 96136 or 96138). The key is that you cannot "double dip", using the time based method for determining the E&M that encompasses the same time used for the 96130, 96136, or 96138.

LSW, LPC Etc Only: LSW, LPC, and equivalent cannot bill any codes on this billing guide 90791 is the code designed to cover psychological screening, testing, and evaluation services

General Limitations: The following are considered not medically reasonable:

Routine re-evaluation of chronically disabled patients that is not required for a diagnosis or continued treatment is not medically reasonable and necessary.

Brief screening measures such as the Folstein Mini-Mental Status Exam or use of other mental status exams in isolation should not be classified separately as psychological or neuropsychological testing, since they are typically part of a more general clinical exam or interview.

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ICD-10 Reference Guide Examples of NON-Mental Health ICD-10 Codes

Symptoms of Depression Chronic Fatigue Insomnia Sleep Disturbances Pain in Joints/ Multiple Sites Myalgia/ Myositis Anorexia Abnormal Weight Gain Abnormal Weight Loss Decreased Libido

Symptoms of Anxiety and SSD Abdominal Pain Indigestion Diarrhea Dry Mouth Pounding or Racing Heart Chest Pain Sighing Rapid Breathing Sweating Lightheadedness Dizziness Syncope Headache Insomnia Sleep Disturbances

Symptoms of Bipolar Altered Mental Status Attention Deficit Irritability Impulsiveness Nervousness Dizziness

Symptoms of ADHD Palpitations Attention Deficit Altered Mental Status Irritability Impulsiveness Nervousness Constipation Insomnia Sleep Disturbances

Symptoms of SUD Alcohol Dependence Opioid Dependence

Other Symptoms Fecal Incontinence Urinary Frequency Epilepsy Alzheimer Multiple Sclerosis Cardiovascular Disease Vertigo Myocardial Infarction Valvular Heart Disease Congestive Heart Failure Hypertension Arteriosclerosis COPD Asthma Emphysema Obstructive Sleep Apnea Chronic Bronchitis Polycystic Kidney Disease Urinary Incontinence Stress Incontinence Diabetes Metabolic Syndrome Hypothyroidism Hyperthyroidism Back Pain Cerebrovascular Disease

Examples of Mental Health ICD-10 Codes

Major Depressive Disorder Persistent Depressive Disorder Generalized Anxiety Disorder Bipolar 1 Disorder Bipolar 2 Disorder

Somatization Disorder Attention-deficit Hyperactivity Disorder Alcohol Dependence Opioid Dependence Irritability and Anger

Modifiers

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The following modifiers should be used together when billing all mental health codes. Failing to use modifiers correctly WILL cause a denial of your claim in most situations. Modifier 25 Must be present on the E&M code and the E&M code must be first on the CMS form. Modifier 59 Must be present on the Mental Health code and the Mental Health code must be after the E&M code

on the CMS form.

Sample CMS 1500

Disclaimer

The following information is meant as a general guideline and is not guaranteed to be accurate. This information should not replace the advice of a certified coder or healthcare attorney. Any dollar amounts listed are based on averages at the time and should be verified with your own insurance contracts or representatives. They are not a guarantee of payment or results.

Sample Documentation

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96127 Documentation

Place in a separate section of the encounter narrative with a label like "Mental Health Screening"

"As part of their intake patient was screened for depression, anxiety, adhd, substance use disorder, bipolar disorder, and somatic symptom disorder. Results were negative for all conditions."

96138 Documentation

Place in a separate section of the encounter narrative with a label like "Mental Health Testing"

"Patient presented with symptoms comorbid to multiple psychological conditions. A mental health screening was administered showing the need to perform additional testing for [list at least 2 conditions that they triggered (positive OR pertinent negative)]. Validated Standardized Assessments were performed and scored by a technician using a computerized interview tool along with verbal confirmation, following the DSM-V criteria, taking a total time of [list total time (not just facetime) - between 16 and 30] minutes."

96130 Documentation

Place in a separate section of the encounter narrative with a label like "Mental Health Testing Interpretation and Report"

"On consolidation and review of the results of the mental health screening, the detailed computerized tests conducted by a techician, and verbal interview by a technician, I have concluded that the patient has [list at least one positive condition with severity and score, and suicide risk if applicable] which have the potential to cause complications with [list one or two physical contions if applicable]. The results and diagnosis were discussed with the patient and they were given an opportunity for interactive feedback. Patient agreed to the treatment plan. The total consolidation and review took [list total time (not just facetime) - between 31 and 60] minutes."

Documentation Intent

Make sure that it is clear in your documentation that the services billed for 96127, 96136, 96138, or 96130 are separate and unique from the services performed as part of the E&M. If the separation is not clear in your documentation, your mental health codes may be considered bundled with the E&M and they will not be paid.

Additional Considerations

96130 is time based and must include documentation showing that it took at least 31 minutes. If the total time with the patient consolidating information and writing a report was at least 91 minutes then 96131 may be billed after the 96130 for an additional $90.97.

96136 and 96138 are time based and must include documentation that they took at least 16 minutes. If the total time with the administering tests and interviewing the patient was at least 46 minutes then 96137 or 96139 may be billed after the 96136 or 96138 for an additional $41.16 or $36.76.

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