Technical Details
When Can You Use Psychological Tests?
Psychological tests can be given whenever they are medically necessary, and therefore billable. This means when 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 the Center for Medicare and Medicaid Services (CMS).
Who Can Use and Bill Testing Codes?
CMS states: More specifically,… the CPT codes for psychological and neuropsychological tests include tests performed by technicians and computers (CPT codes 96102, 96103, 96119 and 96120) in addition to tests performed by physicians, clinical psychologists [CPs], independently practicing psychologists and other qualified nonphysician practitioners … such as nurse practitioners (NPs), clinical nurse specialists (CNSs), and physician assistants (PAs).*(page 1)
Must NPs, CNSs, or PAs be Supervised?
CMS states: Moreover, 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 supervision requirements of the diagnostic psychological and neuropsychological tests benefit, that is, under the general supervision of a physician or a CP.*(page 2)
… rather … NPs and CNSs must perform such tests under the requirements of their respective benefit. Therefore, NPs and CNSs must perform them in collaboration (as defined under Medicare law at section 1861(aa)(6) of the Act) with a physician. Likewise, PAs must perform these tests under the general supervision of a physician as required for services furnished under the PA benefit.*(pages 2-3)
What about PTs, OTs and SLPs?
These professionals are not authorized to bill psychological testing codes. There are three special codes that they are allowed.:“… physical therapists (PTs), occupational therapists (OTs) and speech language pathologists (SLPs) are authorized to bill three test codes (96105, 96110, and 96111) as “sometimes therapy” codes. However, when PTs, OTs and SLPs perform these three tests, they must do so under the general supervision of a physician or a CP.”*(page 3)
TestSTAT does have tools for PT, OT and SLP use that are billable under their respective benefits. But, that’s a different story best told on another day on another website. Contact us at the bottom of this page, as we have programs for dementia assessment by OTs that generate good income streams.
When To Use an Assistant?
When computer-administered testing CPT codes 96103 (psychological) and 96120 (neuropsychological) are billed, they include interpretation and reporting of the tests by a qualified HCP; i.e., a physician, NP, PA or psychologist: These codes 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 (96102/96119) should be used. (from: AMA CPT Assistant, November, 2006)
The PME does require considerable assistance to take. Since it is comprehensive patients will need help understanding some questions. They will need assistance taking BP readings, as well as their height, weight and waist measurements. Since there is significant interaction needed, we recommend using an assistant and billing 96102 for the PME.
Supervision of Assistants
CMS has defined supervision under the Code of Federal Regulations or CFR Act. CMS has a regulation** that allows either a clinical psychologist (CP) or a physician to provide the required general supervision for diagnostic psychological and neuropsychological tests. (CMS FAQ 417)
CMS describes levels of physician supervision required for furnishing the technical component of diagnostic tests for a Medicare beneficiary who is not a hospital inpatient or outpatient. Section 410.32(b) of the Code of Federal Regulations (CFR) requires that diagnostic tests covered under §1861(s)(3) of the Act and payable under the physician fee schedule, with certain exceptions listed in the regulation, have to be performed under the supervision of an individual meeting the definition of a physician (§1861(r) of the Act) to be considered reasonable and necessary and, therefore, covered under Medicare. The regulation defines these levels of physician supervision for diagnostic tests as follows:
• General Supervision - means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel who actually performs the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.
• Direct Supervision - in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed.
• Personal Supervision - means a physician must be in attendance in the room during the performance of the procedure.
(CMS Manual System, Transmittal 51, 06/23/06)
NPs, CNSs, and PAs
CMS says: “Nurse practitioners, clinical nurse specialists, and physician assistants are not defined as physicians … when these practitioners personally perform diagnostic tests as provided under … the Act, … does not apply and they may perform diagnostic tests pursuant to State scope of practice laws and under the applicable State requirements for physician supervision or collaboration.” Thus, they act as Health Care Providers (HCPs) within the scope of their profession in collaboration with a physician.
One could interpret that since NPs, CNSs, and PA’s are not defined as physicians and are required to “personally perform” psychological tests (in order to avoid supervision requirements) that this might exclude them from using assistants; i.e. billing under their names for CPT 96102 (technician assisted testing). However, this does not appear to be CMS’ intention or position. For example, while the Medicare Benefits Policy Manual notes that students or trainees cannot receive payment for these codes, it also goes on to state:
Medicare does not pay for services represented by CPT codes 96102 and 96119, when performed by a student or a trainee. However, the presence of a student or a trainee while the test is being administered does not prevent a physician, CP, IPP, NP, CNS or PA from performing and being paid for the psychological test under 96102 or the neuropsychological test under 96119 (Chapter 15, Section 80.2).
Thus, CMS states that just like a physician, clinical psychologist (CP), independently practicing psychologist (IPP), NP, CNS or PA should be able to perform and be paid for technician assisted, computer administered psychological testing (CPT 96102) whether a student is present or not. Remember, Medicare is fickle so always consult your billing consultant–but they do appear to clearly state this.
Psychologists
When a clinical psychologist (CP) uses an employed assistant and bills that employee’s services as “incident to” him/herself the services must be “performed under the direct personal supervision of the CP; i.e., the CP must be physical present and immediately available.” Incident to billing means the CP bills as if s/he did the services personally. Since there are now testing codes for tests given directly by a CP, or by a computer, or by an assistant there is no longer a reason to use incident to billing (other than to generate maximum revenue) so we do not advise using incident to billing any longer. Otherwise CMS states the CP can supervise assistants; i.e., “Diagnostic psychological testing services [are payable] when furnished under the general supervision of a CP.”
Care needs to be used, because some psychological associations issue ethical statements beyond CMS criteria and should be followed if the CP belongs to that association. For example, the American Psychological Association’s Division of Neuropsychology defines the use of a technician more specifically and states the CP should provide direct supervision when the technician performs neuropsychological (NP) testing. Thus, it would appear assistants could do PMEs in nursing facilities, patient homes, etc. under the general supervision of a medical HCP who is not present; however, assistants working under a psychologist should only work within the same office suite where the psychologist is present.
This writer can find no position statements for “assisted computer administered” testing, but general supervision of the technician by the CP is required by Medicare. Clearly, the level of a technician’s skill in helping a patient take a computer administered test would be less than for a technician actually administering neuropsychological tests, so general supervision might well suffice. However, a CP might wish to discuss and verify the level of supervision needed, with colleagues and his/her professional organization’s practice management advisors.
CP’s should remember that when they applied for a Medicare provider number they signed an agreement that, with patient permission, they would attempt to consult with the patient’s PCP. This includes notifying the PCP of providing services to the patient, unless the patient was referred by the PCP to the CP of course. Providing the PCP with a copy of the PME is an excellent way of meeting this requirement.
Additional Points
A pleasant detail is that diagnostic psychological and neuropsychological tests are not subject to the outpatient mental health treatment limitation, which is the payment limitation on treatment for mental health services. This is called the “psychiatric reduction” and allows Medicare to reduce it’s physician schedule fees for counseling and psychiatry services by up to 50%. This is being gradually undone by pressure for “parity” between mental and medical services, but at least psychological testing is not penalized for being a non-medical service. Sadly, any physician entering mental health practice will face little competition from psychiatrists, psychologists and social workers who represent the bulk of the 2% of providers who have opted out of Medicare.
The technician and computer CPT codes for psychological tests include practices expense, malpractice costs and professional work relative value units. Thus, interpretation of the results should be included and the PME generates a professional report which can be referenced by the HCP in working with the patient.
Disclaimer
The information here is believed the most current and appropriate, but insurance companies change their rules and policies often. While the information here has been stable and is referenced, please note that it is not intended as instruction in how to bill for or perform healthcare procedures. TestSTAT and it’s agents accept no responsibility for the payment, coding, billing or personnel information if used by anyone reading this website and it’s material. You should consult with the coding and billing experts serving your office for information specific to your practice.
*CMS: MLN Matters: MM5204. Information for Medicare Fee-For-Service Health Care Professionals, updated 11/08/12. (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/mm5204.pdf)
**42 CFR 410.32(b)(2)(iii)