Pain & Wellness (Quality of Life) Evaluation is Reimbursable
What Codes Medicare and Insurances Pay For
Psychological testing can be performed (or overseen) by any health care provider (HCP) defined as a person who is trained and licensed to give health care. This includes a physician, nurse practitioner, physician’s assistant or a psychologist. There are three CPT codes under which the PME is billable:
• CPT 96101 is billed when the HCP personally performs the testing and interprets the findings with the patient; i.e., reviews results and develops a treatment plan.
• CPT 96102 is billed when a technician administers the tests. The test results are interpreted and reported by the HCP.
• CPT 96103 is billed when the testing is done on a computer without significant human assistance. The test results are interpreted and reported by the HCP.
For computer-administered testing: if the HCP is present and assists–use 96101; if a technician is available and assists–use 9102; if no one substantially assists then use 96103. The codes can be mixed and matched on the same day, as long as the services they represent are distinct from each other. See the Technical Reference for details about this. Please also see our disclaimer in the next section, as the information offered here is not meant to replace your practice’s expert coding and billing consultation.
Billing is by the hour-unit (an hour is defined as 31 to 90 minutes), for example if testing took 35 minutes, as the PME typically does, you would bill one unit of testing. Rates vary by region, but for computer-administered testing, Medicare allows about $30/unit when minimal assistance (96103)* is offered; $70/unit when a technician assists throughout testing; and, $100/unit when a HCP is present throughout. Up to 8 units can be billed per patient, and even more if a rationale is provided to Medicare. Time varies according to patient speed but if it takes 91 minutes than two units would be billed. Billing one to two units (for a slow test taker) per patient is not likely to trigger an audit. You can even bill for less than 31 minutes of testing by including the -52 modifier with the CPT code, but we have had to do this.
To find out what Medicare allows per unit in your area, click here accept the disclaimer and select "All Modifiers", a MAC location (your state), and an HCPCS code like "96102" for a technician assisted testing, or "96101" if you plan to give the test yourself. You'll see two allowed rates (Prices) for either outpatient or non-facility and inpatient or facility (like a hospital). The facility rate is always much cheaper as they assume an office, etc. is provided for you–which, of course, is nonsense in my 35+ years of hospital consulting. The hospital also gets paid a separate facility fee by Medicare, which doesn't help a consultant working there, as this writer knows from decades of doing low paid hospital consults.
Assisted Testing
If a technician substantially “assists” the patient than the CPT code is 96102.** For example s/he sets up the testing session on an iPad tablet, answers questions, helps enter some data, takes BP readings, height and weight, etc. Most important is that the technician is present with the patient throughout the testing; i.e., immediately available or nearby, and ready to assist. The PME is intuitive and user friendly, and many people have successfully taken it at home on their own, in which case 96103 is billed. However, we find most folks will need occasional assistance during the testing.
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There is no special educational requirement for technicians. The technician may not interpret results (e.g., report or explain them to a patient) as this must be done by the HCP. TestSTAT provides instant results in a PDF report which is emailed to you, thus you can refer to the results in an appointment right after the testing. The HCP can additionally bill for face-to-face time with the patient, charting the findings, dictating a note, integrating findings with medical information, etc. via units of 96101 to represent their (not the technician’s) expertise and personal involvement. In fact, Magellan’s Psych Testing FAQs notes that “if the 96102 or the 96103 code is used the 96101 must also be used (this is because [a HCP] must interpret the psych test results).” But, this seems to contrast with this is CMS’ statement:
The technician and computer CPT codes for psychological and neuropsychological tests include practice expense, malpractice expense and professional work relative value units. Therefore, CPT psychological test code 96101 will not be paid if you include it in the bill for the same tests or services performed under psychological test codes 96102 or 96103.***
We understand this to mean if a HCP spends personal professional time as part of computer-administered testing (i.e., focused on the PME) then it should be billed as units of 96102. But, if the HCP looks at other factors and personally gives additional tests, than units of 96101 should be billed. Remember up to 8 hour units can be billed per patient. Again, please consult your own billing consultant and note our disclaimer at the bottom of the next section.
Since the Pain Management Evaluation is taken online and scored instantly and the Report emailed to the HCP within a few minutes, a “feedback” session can be scheduled right after the test is completed; i.e., on the same day or at a later appointment. One of the best things about the psychological testing codes can be billed with other (e.g., E&M) codes on the same day.
Feedback Options (see our disclaimer)
There are various options to bill for sharing the results of the PME with the patient as well as for treatment planning based on its findings. If the HCP personally charts, interprets and/or reviews findings from a computer-administered PME with the patient or family then s/he can bill additional CPT 96101 for about $100 per hour (≥31 minutes) on the same day, up to 8 hours although no more than 1-2 hours is recommended.
If the HCP utilizes PME findings in a larger context of the patient’s medical status, s/he might bill an E&M code on the same day, or at a later appointment.
Two other codes often used involve Psychiatric Evaluation, which are especially useful if the PME is done along with an initial psychiatric intake on the same day. These codes are not time-based, rather you document history, mental status (based on appearance/behavior of the patient) and a starting treatment plan design. The two codes are:
90791 Psychiatric evaluation exam (no medical services - Non-Prescriber; e.g., CP, SW or licensed counselor). To take a complete medical and psychiatric history, a mental status examination, Integrated biopsychosocial assessment, and an evaluation of the patient's ability and capacity to respond to treatment on an initial plan of treatment. One allowed per client per provider per year. (National Av. Reimb. $132.48 as of 4/24/16)
90792 Psychiatric evaluation exam (with medical services - Prescriber.) To take a complete medical and psychiatric history, a mental status examination, Integrated biopsychosocial assessment, and an evaluation of the patient's ability and capacity to respond to treatment on an initial plan of treatment. One allowed per client per provider per year (National Av. Reimb. $146.44 as of 4/24/16)
OPTUM’s Reimbursement policy describes: CPT Codes 90791 and 90792 may be billed once per day. However, only one code may be billed by the same provider daily. If 90792 and 90791 are billed on the same day, by the same individual provider, 90791 will be denied. Additionally, evaluation and management, psychotherapy, and crisis management services may not be billed by the same provider on the same day as a psychiatric diagnostic evaluation. Claim submissions not in compliance with this rule will be denied.
Based upon the 2014 CPT Manual the following CPT Codes, noted below, may not be billed in conjunction with CPT Code 90791 and CPT Code 90792 by a single provider on the same date of service:
Billing is by the hour-unit (an hour is defined as 31 to 90 minutes), for example if testing took 35 minutes, as the PME typically does, you would bill one unit of testing. Rates vary by region, but for computer-administered testing, Medicare allows about $30/unit when minimal assistance (96103)* is offered; $70/unit when a technician assists throughout testing; and, $100/unit when a HCP is present throughout. Up to 8 units can be billed per patient, and even more if a rationale is provided to Medicare. Time varies according to patient speed but if it takes 91 minutes than two units would be billed. Billing one to two units (for a slow test taker) per patient is not likely to trigger an audit. You can even bill for less than 31 minutes of testing by including the -52 modifier with the CPT code, but we have had to do this.
To find out what Medicare allows per unit in your area, click here accept the disclaimer and select "All Modifiers", a MAC location (your state), and an HCPCS code like "96102" for a technician assisted testing, or "96101" if you plan to give the test yourself. You'll see two allowed rates (Prices) for either outpatient or non-facility and inpatient or facility (like a hospital). The facility rate is always much cheaper as they assume an office, etc. is provided for you–which, of course, is nonsense in my 35+ years of hospital consulting. The hospital also gets paid a separate facility fee by Medicare, which doesn't help a consultant working there, as this writer knows from decades of doing low paid hospital consults.
Assisted Testing
If a technician substantially “assists” the patient than the CPT code is 96102.** For example s/he sets up the testing session on an iPad tablet, answers questions, helps enter some data, takes BP readings, height and weight, etc. Most important is that the technician is present with the patient throughout the testing; i.e., immediately available or nearby, and ready to assist. The PME is intuitive and user friendly, and many people have successfully taken it at home on their own, in which case 96103 is billed. However, we find most folks will need occasional assistance during the testing.
n
There is no special educational requirement for technicians. The technician may not interpret results (e.g., report or explain them to a patient) as this must be done by the HCP. TestSTAT provides instant results in a PDF report which is emailed to you, thus you can refer to the results in an appointment right after the testing. The HCP can additionally bill for face-to-face time with the patient, charting the findings, dictating a note, integrating findings with medical information, etc. via units of 96101 to represent their (not the technician’s) expertise and personal involvement. In fact, Magellan’s Psych Testing FAQs notes that “if the 96102 or the 96103 code is used the 96101 must also be used (this is because [a HCP] must interpret the psych test results).” But, this seems to contrast with this is CMS’ statement:
The technician and computer CPT codes for psychological and neuropsychological tests include practice expense, malpractice expense and professional work relative value units. Therefore, CPT psychological test code 96101 will not be paid if you include it in the bill for the same tests or services performed under psychological test codes 96102 or 96103.***
We understand this to mean if a HCP spends personal professional time as part of computer-administered testing (i.e., focused on the PME) then it should be billed as units of 96102. But, if the HCP looks at other factors and personally gives additional tests, than units of 96101 should be billed. Remember up to 8 hour units can be billed per patient. Again, please consult your own billing consultant and note our disclaimer at the bottom of the next section.
Since the Pain Management Evaluation is taken online and scored instantly and the Report emailed to the HCP within a few minutes, a “feedback” session can be scheduled right after the test is completed; i.e., on the same day or at a later appointment. One of the best things about the psychological testing codes can be billed with other (e.g., E&M) codes on the same day.
Feedback Options (see our disclaimer)
There are various options to bill for sharing the results of the PME with the patient as well as for treatment planning based on its findings. If the HCP personally charts, interprets and/or reviews findings from a computer-administered PME with the patient or family then s/he can bill additional CPT 96101 for about $100 per hour (≥31 minutes) on the same day, up to 8 hours although no more than 1-2 hours is recommended.
If the HCP utilizes PME findings in a larger context of the patient’s medical status, s/he might bill an E&M code on the same day, or at a later appointment.
Two other codes often used involve Psychiatric Evaluation, which are especially useful if the PME is done along with an initial psychiatric intake on the same day. These codes are not time-based, rather you document history, mental status (based on appearance/behavior of the patient) and a starting treatment plan design. The two codes are:
90791 Psychiatric evaluation exam (no medical services - Non-Prescriber; e.g., CP, SW or licensed counselor). To take a complete medical and psychiatric history, a mental status examination, Integrated biopsychosocial assessment, and an evaluation of the patient's ability and capacity to respond to treatment on an initial plan of treatment. One allowed per client per provider per year. (National Av. Reimb. $132.48 as of 4/24/16)
90792 Psychiatric evaluation exam (with medical services - Prescriber.) To take a complete medical and psychiatric history, a mental status examination, Integrated biopsychosocial assessment, and an evaluation of the patient's ability and capacity to respond to treatment on an initial plan of treatment. One allowed per client per provider per year (National Av. Reimb. $146.44 as of 4/24/16)
OPTUM’s Reimbursement policy describes: CPT Codes 90791 and 90792 may be billed once per day. However, only one code may be billed by the same provider daily. If 90792 and 90791 are billed on the same day, by the same individual provider, 90791 will be denied. Additionally, evaluation and management, psychotherapy, and crisis management services may not be billed by the same provider on the same day as a psychiatric diagnostic evaluation. Claim submissions not in compliance with this rule will be denied.
Based upon the 2014 CPT Manual the following CPT Codes, noted below, may not be billed in conjunction with CPT Code 90791 and CPT Code 90792 by a single provider on the same date of service:
However, either CPT Codes 90791 or 90792 can be billed on the same day as one of the psychological test codes, at least to Medicare.
An Income Model
A doctor’s office could use up two or three internet connected wifi tablets. Android or Apple iOS is fine. Hire a $15/hour technician with basic skills in: computer use (e.g., entering identifying data); train them in measuring height, weight and blood pressure with the Omron wrist BP device, etc. Have all new patients and existing patients with pain complaints test on two days/evenings (when office use is low) of the week. The HCP need not be physically present or "under the same roof."
Just two testings per hour across two six-hour testing days, would yield 24 assessments per week generating $1440 – $200 in staff costs = $1240 gross income per week. TestSTAT charges per test administration, about 10-15% of gross leaving you with about $1050/week or $50,000 per year. And, you are doing PQRS/MACRA evaluations at the same time.
Physicians, NPs and PAs who wish to move into mental health areas, like treating substance abuse patients might, in addition to the PME, do 10+ psychiatric interviews (90792) in a day, thus billing Medicare $146 each for $1460 per day (remember this code is not timed). Of course, you would use the PME report to help guide your psychiatric interview. 10 PME’s generates $700/day – tests cost $150 – the assistant costs $150 = $400 daily income. Net income per day would be $1860 or $9300 per week. Note this is for 10 patients per day while using one assistant.
10 patients per day is about 1/3 of the number of patients a PCP sees daily and the average PCP doesn't make $446,000 for a 48 week year! Even just working half-time (seeing 5 patients daily) would generate far more than a PCP earns full-time seeing 30+ patients per day.
As doctors move into new areas of treatment like Suboxone management, they are taking on a greater mental health provider role which is appropriate in the primary care setting. In fact, all indicators point towards mental health being overseen by PCPs and integrated into medical practices in future. The challenge is in billing for these services, instead of doing more free useless brief screenings. And, the PME appears to be a good solution. Especially, since you are limited on how many Suboxone patients you can carry.
Want More Information?
You can really drill down into the details in the next section: Technical Reference which addresses the specifics of supervision, who can test and bill, etc. This presents the supporting data from CMS for the ideas presented here, but once again we remind you to read our disclaimer at the bottom of the Technical Reference. Medicare is fickle and you should consult your own expert billing and practice management advisors and not just rely on our interpretations of CMS rules. If you would like to learn more about the Pain Management Evaluation, contact Dr. GPE by clicking on the link at the bottom of this page.
An Income Model
A doctor’s office could use up two or three internet connected wifi tablets. Android or Apple iOS is fine. Hire a $15/hour technician with basic skills in: computer use (e.g., entering identifying data); train them in measuring height, weight and blood pressure with the Omron wrist BP device, etc. Have all new patients and existing patients with pain complaints test on two days/evenings (when office use is low) of the week. The HCP need not be physically present or "under the same roof."
Just two testings per hour across two six-hour testing days, would yield 24 assessments per week generating $1440 – $200 in staff costs = $1240 gross income per week. TestSTAT charges per test administration, about 10-15% of gross leaving you with about $1050/week or $50,000 per year. And, you are doing PQRS/MACRA evaluations at the same time.
Physicians, NPs and PAs who wish to move into mental health areas, like treating substance abuse patients might, in addition to the PME, do 10+ psychiatric interviews (90792) in a day, thus billing Medicare $146 each for $1460 per day (remember this code is not timed). Of course, you would use the PME report to help guide your psychiatric interview. 10 PME’s generates $700/day – tests cost $150 – the assistant costs $150 = $400 daily income. Net income per day would be $1860 or $9300 per week. Note this is for 10 patients per day while using one assistant.
10 patients per day is about 1/3 of the number of patients a PCP sees daily and the average PCP doesn't make $446,000 for a 48 week year! Even just working half-time (seeing 5 patients daily) would generate far more than a PCP earns full-time seeing 30+ patients per day.
As doctors move into new areas of treatment like Suboxone management, they are taking on a greater mental health provider role which is appropriate in the primary care setting. In fact, all indicators point towards mental health being overseen by PCPs and integrated into medical practices in future. The challenge is in billing for these services, instead of doing more free useless brief screenings. And, the PME appears to be a good solution. Especially, since you are limited on how many Suboxone patients you can carry.
Want More Information?
You can really drill down into the details in the next section: Technical Reference which addresses the specifics of supervision, who can test and bill, etc. This presents the supporting data from CMS for the ideas presented here, but once again we remind you to read our disclaimer at the bottom of the Technical Reference. Medicare is fickle and you should consult your own expert billing and practice management advisors and not just rely on our interpretations of CMS rules. If you would like to learn more about the Pain Management Evaluation, contact Dr. GPE by clicking on the link at the bottom of this page.
*If the interaction between the patient and the technician is limited to installing the program and checking that the patient is able to complete the test and providing some basic assistance, than CPT 96103 should be billed. Adapted from AMA CPT Assistant, Nov., 2006.
**If greater levels of interaction are required, though the test may be computer administered, than the appropriate technician code (CPT 96102) should be used. Measures designed for use in the doctor’s office that involve substantial patient/technician interaction warrant CPT 96102. AMA CPT Assistant, Nov., 2006.
***CMS: MLN Matters: MM5204. Information for Medicare Fee-For-Service Health Care Professionals, updated 11/08/12, p 4. (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/mm5204.pdf)