Disclaimer: TestSTAT can not guarantee accuracy of the following comments on billing, coding and income. We accept no liability for statements made here, except that they are as accurate as we can determine. Medicare uses regional intermediaries (MACs) around the US to manage billing, and each intermediary may have different rules and regulations. Users of TestSTAT’s tools should consult with their coding advisors regarding their local MAC's policies.
General Information: Since 1966 the Center for Medicare and Medicaid Services (CMS) has used fiscal intermediaries all around the US to process medical claims for Medicare. As part of the Medicare Prescription Drug Act (Part D) these were replaced
by regional Medicare Administrative Contractors (called MACs). For example, our New England Medicare billings are submitted to NGS (National Government Services) highlighted in red on the adjacent map. MACs compete for contracts to manage Medicare affairs and they change now and then. Thus, after many years our MAC in Hingham, MA lost
its contract to NGS, based on the west coast, which had different interpretations of some rules we were used to. Each MAC may have slightly different rules based on how they interpret CMS regulations. Thus, we look to the CMS regulations and note them here and on our Technical Reference page of this website. While generally accurate, there can be regional and other differences–please note our disclaimer, above.
Frequently Asked Questions
Can psychological tests be used with most patients?
Yes. Psychological tests can be given whenever they are medically necessary, and therefore billable. This means whenever they might be used to help a clinician better understand the nature of a patient’s illness, for recommendations regarding coping with and compensating for their difficulties and encouraging treatment adherence. Most third party payors follow the guidelines and rules promulgated by CMS. Sections 1833(c), 1861(s)(2)(C), 1861(s)(3), and 1842(b)(2)(A) of the Social Security Act are explained in Chapter 15 of the CMS Benefits Policy Manual which states:
"Psychological and Neuropsychological Testing are diagnostic procedures that must be used as an important tool in making specific diagnoses or prognoses to aid in treatment planning and to address questions regarding treatment goals, efficacy, and patient disposition. Diagnostic procedures that have no impact on a patient’s plan of care or have no effect on treatment are not medically necessary."
Can non-psychologists perform and bill for psychological testing?
Yes. CMS states: Medicare Part B payment is authorized for cpt codes 96101, 96102, 96103… under section 1842(b)(2)(A) of the SSA "when performed by physicians, clinical psychologists … and other qualified nonphysician practitioners… such as nurse practitioners (NPs), clinical nurse specialists (CNSs), and physician assistants (PAs). – (Medicare Learning Network, MLN Matters #5205)"
Can students perform and bill for psychological testing?
No, the Manual states: "Under the physician fee schedule, there is no payment for services performed by students or trainees. Accordingly, Medicare does not pay for services represented by CPT codes 96102 and 96119 [neuropsych. testing] when performed by a student or a trainee."
If a non-physician provider does psych. testing, must s/he be supervised?
No. Per section 1842(b)(2)(A) of the Social Security Act: "…nonphysician practitioners such as nurse practitioners (NPs), clinical nurse specialists (CNSs) and physician assistants (PAs) who personally perform diagnostic psychological and neuropsychological tests are excluded from having to perform these tests under the general supervision of a physician or a CP [Clinical Psychologist]. Rather, NPs and CNSs must perform such tests under the requirements of their respective benefit… Accordingly, NPs and CNSs must perform tests in collaboration (as defined under Medicare law at section 1861(aa)(6) of the Act) with a physician. PAs perform tests under the general supervision of a physician as required for services furnished under the PA benefit."
Are only certain providers allowed to bill insurances for the Pain Management Evaluation (PME) or any other TestSTAT computer-administered measure?
Yes. The CMS (Medicare/Medicaid) will only reimburse a CP (Clinical Psychologist), MD, DO, PA or NP; i.e., a licensed Health Care Provider (or HCP). Unfortunately, these are the only HCPs allowed to bill Medicare, and thus most insurances. Chiropractors, podiatrists, etc. would be ideal PME users given the pain their patients present with, but they are not allowed reimbursement for any type of psychological testing. Interestingly, NPs and PAs supervised by an MD or DO, but working in a chiropractor or foot doctor's office would likely be able to bill. Most health insurances follow CMS’ rules.
Can PTs. OTs, or Speech Therapists–can bill for the PME?
No. See the Technical Reference page on this website for specifics.
Is the PME's user documented in the report?
Yes. The HCP’s name always appears on the PME’s report as the Clinician, documenting who ordered and billed for the the PME. A procedure always needs to be billed under a specific HCP. If a HCP uses an assistant; s/he should be tied to the HCP billing for the test procedure, thus their name also appears on the report as the test Administrator. An assistant can work as an administrator under multiple different Clinicians or HCPs
Is the payment rate different if a patient self-takes the PME vs. it being given by a HCP vs. given by an assistant?
Yes. Any procedure billed to any insurer usually must be listed in the ever-changing Current Procedure Terminology (CPT) list of billable procedures. CMS uses the Healthcare Common Procedure Coding System (HCPCS) which is just another way of saying CPT. The CPT is published by the AMA and is a huge money maker for them; the paperback book below (one of several versions) costs $89–on sale.
For example if a patient undergoes computer-administered psychological testing, it is billed under the following CPT codes and reimbursed by Medicare in the Boston area at about:
$29 cpt 96103: Self-takes the test.
$71 cpt 96102: An assistant helps the pt.
$83 cpt 96101: A HCP helps the pt.
$71 cpt 96102: An assistant helps the pt.
$83 cpt 96101: A HCP helps the pt.
You can see that, for a provider, the reimbursement "sweet spot" is using a $12–$18/hr assistant to make $40 more than letting the patient take a test alone. An assistant generates just $11 less per hour-unit than if the HCP gave the test personally.
What differentiates cpt 96103 from 96202
CPT codes 96103 "should be reserved for situations where the computerized testing is unassisted by a provider or technician other than the installation of programs/test and checking to be sure that the patient is able to complete the tests. If greater levels of interaction are required, though the test may be computer administered, then the … technician code (96102) should be used." (quoted from: AMA CPT Assistant, November, 2006, bolded print mine.)
Can the Assistant or Clinician assist more than one patient at a time?
That appears so. There is nothing in the regulations specifying how an assistant helps a patient other than that assistance should be substantial enough to set it apart from just setting someone up to work independently in front of a computer. Staggering appointments at 15 minute intervals could allow an Assistant to set up four patients an hour, and sitting in the same room with them taking BPs, weights, waste sizes, and recording recent cholesterol levels into their protocols, answering questions, etc. for all would constitute substantial help to each, in our opinion.
What is the reimbursement rate above 60 minutes?
All psychological testing codes (there are a dozen of them) pay per “unit” of testing.
≥31” but ≤ 90" bill 1 unit
≥91” but ≤ 150” bill 2 units
≥151” but ≤210” bill 3 units
≥211” but ≤300” bill 4 units, etc.
≥91” but ≤ 150” bill 2 units
≥151” but ≤210” bill 3 units
≥211” but ≤300” bill 4 units, etc.
Units are based on time and are rounded off to the next half hour. So you can't bill for 30 minutes or less (unless you use the –52 modifier), but for ≥31" you can bill a unit. Anything from 31" to 90" minutes rounds to 1 unit, but at ≥91 minutes you bill 2 units.
Here's a guide, above, for how many units to bill for cpt 96101–96103 based on time spent. Luckily, as the patient works through the PME, their exact time spent in testing is recorded, and the PME advises you as to how many units you can bill, on the last page.
What is included in time spent?
If a Clinician or an Assistant spends minimal time setting up a patient to take the PME on a tablet, bill for "unassisted" computer testing, cpt 96103. However, if an assistant spends substantial time (e.g., taking weight, height & BP readings, answering questions, getting information from the patient's record, etc.) and is nearby at all times while the patient is taking the PME then bill cpt 96102, or 96101 if the HCP is assisting.
What if the patient spends only 29 minutes taking the PME?
That's not enough to bill a unit of testing. However, the PME program recognizes when an authorized user (Clinician or Assistant) is reviewing, online, through a patient's protocol after the testing is done, and adds that review time to the total spend which can bring the 29 minutes up to and over 31 minutes. If time is spent offline the PME can't recognize it, but if the Clinician/Assistant documents the time in the EHR (e.g., "2 minutes spent reviewing pt's report for urgent warnings.") that brings testing time up to 31 minutes making it billable as a unit of testing. You just have to add the 2 minutes to the time documented in the PME's report (29") to get 31 minutes or one unit.
How is that documented if the report indicates only 29 minutes?
The Clinician/Assistant can call up the patient's protocol online, and page through it for a few minutes reviewing the answers. Upon arriving at the last page and hitting the submit button will generate a new report PDF and email it. This new report will reflect the additional time spent reviewing the protocol which, hopefully, will exceed 30 minutes to allow billing.
How many units of testing can I bill?
Most Medicare regional intermediaries allow billing up to 8 units of testing on a single patient over one or more days (add up the units and bill all on the last date of service), but ≥9 hours needs a note sent to to the MAC explaining why so much time. We can’t imagine more than 3 hours ever being billed for a PME, unless it’s a remarkably SLOW patient or needs translation, but it would be paid if it happened. Reimbursement is the same for each unit; e.g., for cpt 96102 is allowed $68.67 in the metropolitan Philadelphia areas and $60.86 per unit in the rest of PA, for outpatient or Non-Facility settings.
Does the 80% of physician rate typical for NP and PA services apply?
Not to our knowledge. Our payments have yielded the same rate for nurse practitioners and physician's assistants as for doctors/psychologists for all psychological testing cpt codes. Still, things may differ from MAC to MAC.
Can I bill psych. testing codes as "incident to" to get the higher doctor rates instead of a NP or PA rate?
No. "Psychological tests and Neuropsychological tests are diagnostic procedures and therefore incident to provisions do not apply.(section 1842(b)(2)(A) of the SSA)." This is moot if there is no 20% reduction to NPs or PAs as compared to a physician, anyway. Everyone gets the same rate, we believe.
Are computer administered test procedures paid at different rates for facility vs. non-facility?
Yes. "The payment amounts for…CPT codes 96102, 96103…administered by a technician or a computer reflect a site of service payment differential for the facility and non-facility settings.1842(b)(2)(A) of the SSA)" A non-facility is your practice site, whereas a facility is a hospital or nursing home, which always has a lower allowed rate as CMS believes you save tons of money by getting an office, dictation, phone, etc. paid for by the hospital–something this author has never seen in the many hospitals he has consulted in! The real reason is that Medicare pays facilities a separate fee, yet that penalizes a nonhospital employee like a consultant who visits patients there.
How can I find out what Medicare pays for a cpt code?
To check the allowed rate for Medicare click here and select Accept. Then, click Specific MAC and choose your location from the drop down menu that appears. Select All Modifiers and enter the HCPCS (Healthcare Common Procedure Coding System, based on the CPT) code you want to check (like 96102) and wallah! You'll see what the allowed rate for both facility and non-facility is in your area.
What should we charge for patients who do not have insurance?
The cash pay charge should reflect “what the market will bear” in your area. We’d suggest something on the order of $150 each. Always charge at least $100/unit rate as insurances which pay either their allowed rate or the charge, whichever is lower. You certainly don't want to charge less than Medicare's allowed rate for your MAC.
Can you give the PME more than once per year?
Yes, but there should be a reason noted in the chart as to why this is “medically necessary.” We'd suggest suggest that a HCP make a note in the EHR like: “Pt’s PME results reviewed and advice given. PLAN: repeat PME every 6 months to look for changes in the depression found on original PME testing.” Therefore, yearly administrations would be consistent with the pt’s Medical Plan, if a future audit asks why.
If all patients qualify for yearly testing (e.g., in a pain clinic) assuming it is stated as part of their medical plan, can you justify a high risk patient taking the PME again in 3, 6, or 9 months to see if abuse risk was reduced?
Yes, in fact you may want to retest in several weeks to see if abuse/use risk was increased or reduced. Just knowing a pt went back on cigarettes is a red flag for high risk of drug relapse. Again, there should be a "medically necessary" reason noted in the chart to support this; e.g., “Pt in new recovery just moved to a high-risk neighborhood, repeat PME testing is needed” in the EHR at the end of the appointment to justify repeat testing again soon after the 1st testing.
What, exactly, does medically necessary mean?
In a nutshell, CMS believes a procedure that "has no impact on a patient’s plan of care or have no effect on treatment [is] not medically necessary." Try to document some effect on the patient's care as a result of giving the PME; e.g., when you do your notes about feedback to the patient based on the PME. If no problems are found then note, at least, "Pt advised to keep doing what he is for health maintenance."
How do you print out a the questions on the PME?
The questions for a test are called the test’s “protocol.” The PME’s protocol is displayed page-by-page on a computer screen or iPad as the patient completes each page, then hits the submit button and moves on to the next page. Of course, as long as a page is visible on the screen, it can be printed from the computer/iPad’s browser. You may have alter the print settings; e.g., 90%.
Where are the ICD 10 codes I can refer to and use for billing?
What is included in time spent?
If a Clinician or an Assistant spends minimal time setting up a patient to take the PME on a tablet, bill for "unassisted" computer testing, cpt 96103. However, if an assistant spends substantial time (e.g., taking weight, height & BP readings, answering questions, getting information from the patient's record, etc.) and is nearby at all times while the patient is taking the PME then bill cpt 96102, or 96101 if the HCP is assisting.
What if the patient spends only 29 minutes taking the PME?
That's not enough to bill a unit of testing. However, the PME program recognizes when an authorized user (Clinician or Assistant) is reviewing, online, through a patient's protocol after the testing is done, and adds that review time to the total spend which can bring the 29 minutes up to and over 31 minutes. If time is spent offline the PME can't recognize it, but if the Clinician/Assistant documents the time in the EHR (e.g., "2 minutes spent reviewing pt's report for urgent warnings.") that brings testing time up to 31 minutes making it billable as a unit of testing. You just have to add the 2 minutes to the time documented in the PME's report (29") to get 31 minutes or one unit.
How is that documented if the report indicates only 29 minutes?
The Clinician/Assistant can call up the patient's protocol online, and page through it for a few minutes reviewing the answers. Upon arriving at the last page and hitting the submit button will generate a new report PDF and email it. This new report will reflect the additional time spent reviewing the protocol which, hopefully, will exceed 30 minutes to allow billing.
How many units of testing can I bill?
Most Medicare regional intermediaries allow billing up to 8 units of testing on a single patient over one or more days (add up the units and bill all on the last date of service), but ≥9 hours needs a note sent to to the MAC explaining why so much time. We can’t imagine more than 3 hours ever being billed for a PME, unless it’s a remarkably SLOW patient or needs translation, but it would be paid if it happened. Reimbursement is the same for each unit; e.g., for cpt 96102 is allowed $68.67 in the metropolitan Philadelphia areas and $60.86 per unit in the rest of PA, for outpatient or Non-Facility settings.
Does the 80% of physician rate typical for NP and PA services apply?
Not to our knowledge. Our payments have yielded the same rate for nurse practitioners and physician's assistants as for doctors/psychologists for all psychological testing cpt codes. Still, things may differ from MAC to MAC.
Can I bill psych. testing codes as "incident to" to get the higher doctor rates instead of a NP or PA rate?
No. "Psychological tests and Neuropsychological tests are diagnostic procedures and therefore incident to provisions do not apply.(section 1842(b)(2)(A) of the SSA)." This is moot if there is no 20% reduction to NPs or PAs as compared to a physician, anyway. Everyone gets the same rate, we believe.
Are computer administered test procedures paid at different rates for facility vs. non-facility?
Yes. "The payment amounts for…CPT codes 96102, 96103…administered by a technician or a computer reflect a site of service payment differential for the facility and non-facility settings.1842(b)(2)(A) of the SSA)" A non-facility is your practice site, whereas a facility is a hospital or nursing home, which always has a lower allowed rate as CMS believes you save tons of money by getting an office, dictation, phone, etc. paid for by the hospital–something this author has never seen in the many hospitals he has consulted in! The real reason is that Medicare pays facilities a separate fee, yet that penalizes a nonhospital employee like a consultant who visits patients there.
How can I find out what Medicare pays for a cpt code?
To check the allowed rate for Medicare click here and select Accept. Then, click Specific MAC and choose your location from the drop down menu that appears. Select All Modifiers and enter the HCPCS (Healthcare Common Procedure Coding System, based on the CPT) code you want to check (like 96102) and wallah! You'll see what the allowed rate for both facility and non-facility is in your area.
What should we charge for patients who do not have insurance?
The cash pay charge should reflect “what the market will bear” in your area. We’d suggest something on the order of $150 each. Always charge at least $100/unit rate as insurances which pay either their allowed rate or the charge, whichever is lower. You certainly don't want to charge less than Medicare's allowed rate for your MAC.
Can you give the PME more than once per year?
Yes, but there should be a reason noted in the chart as to why this is “medically necessary.” We'd suggest suggest that a HCP make a note in the EHR like: “Pt’s PME results reviewed and advice given. PLAN: repeat PME every 6 months to look for changes in the depression found on original PME testing.” Therefore, yearly administrations would be consistent with the pt’s Medical Plan, if a future audit asks why.
If all patients qualify for yearly testing (e.g., in a pain clinic) assuming it is stated as part of their medical plan, can you justify a high risk patient taking the PME again in 3, 6, or 9 months to see if abuse risk was reduced?
Yes, in fact you may want to retest in several weeks to see if abuse/use risk was increased or reduced. Just knowing a pt went back on cigarettes is a red flag for high risk of drug relapse. Again, there should be a "medically necessary" reason noted in the chart to support this; e.g., “Pt in new recovery just moved to a high-risk neighborhood, repeat PME testing is needed” in the EHR at the end of the appointment to justify repeat testing again soon after the 1st testing.
What, exactly, does medically necessary mean?
In a nutshell, CMS believes a procedure that "has no impact on a patient’s plan of care or have no effect on treatment [is] not medically necessary." Try to document some effect on the patient's care as a result of giving the PME; e.g., when you do your notes about feedback to the patient based on the PME. If no problems are found then note, at least, "Pt advised to keep doing what he is for health maintenance."
How do you print out a the questions on the PME?
The questions for a test are called the test’s “protocol.” The PME’s protocol is displayed page-by-page on a computer screen or iPad as the patient completes each page, then hits the submit button and moves on to the next page. Of course, as long as a page is visible on the screen, it can be printed from the computer/iPad’s browser. You may have alter the print settings; e.g., 90%.
Where are the ICD 10 codes I can refer to and use for billing?
Can I use a medical diagnosis when billing for the PME?
No. The DSM-5 psychiatric disorder codes, subsumed within the ICD-10's Mental, Behavioral and Neurodevelopment Disorders (codes F01–F99) must be used.
What if no diagnoses are suggested by the PME at all?
If no difficulties are found in the PME and no diagnoses are yielded, consider billing under F32.3 Mild Major Depressive Disorder, single episode. Healthy patients can still be nervous or depressed enough to warrant testing billed under F43.22 Adjustment Disorder with Anxiety or F43.21 Adjustment Disorder with Depressed Mood, or even F43.20 Disease Adjustment (grief). A nice thing about the Adjustment Disorders is, by definition, they don't persist for more than 6 months after a stressor, so they don't follow a patient in their record as a permanent disorder precluding LTC or life-insurance or mess up a job application.
How do I manage all my patient's PME test results?
All protocols are maintained on TestSTAT's mainframe computer. A Clinician or Assistant can review all the protocols for their patients who have taken the PME (even if it is only partially completed) by entering TestSTAT's practice management website, at the portal on the Home page of this site. Reports can be called up to view on the screen, and can be printed from the browser.
Can patients see their report(s)?
Sure. They enter the patient portal on TestMyPain.com and use their name and self-selected password to call up a list of all the reports they have created by taking the PME one or more times. By clicking on the link of any date of testing, then can view online the report and print it from their browser.