Benefit Application
Plans may wish to review their contract language to ensure that the contract language is consistent with the Plan’s medical policy. 

Description
To provide parameters to assist the staff with review benefit request for psychological testing to include neuropsychological testing. This document is not a standard of care, but is developed utilizing industry standard guidelines, peer reviewed literature and current evidence-based recommendations.

SCOPE

If appropriate, psychological or neuropsychological testing may be used to enhance behavioral health outcomes. Psychological tests are only a single component of a psychological assessment and are not a substitute for a detailed clinical interview, including a comprehensive history and a review of psychological, medical, educational and other relevant records. These services may be provided to evaluate areas such as symptom definition and quantification, personality inventories, cognitive assessment (IQ, memory, perception, attention, language and motor skills), measurements of stress and social function, and scales to define a person’s ability to utilize treatment modalities.

A complete biopsychosocial evaluation should be performed by a clinician, appropriate to their level of training and expertise. After testing, a report should be produced and presented to the patient and/or guardians which should include a complete mental status examination including cognitive components, a complete history of the current situation and any past treatment, family and social history, results of the testing and an interpretation section with treatment impact and recommendations. A neurological exam may be also indicated. The current Diagnostic and Statistical Manual for Mental Disorders clearly delineates highly specific criteria for clinical diagnoses, which should allow clinicians to make a clinical working diagnosis a majority of the time.

Policy 
MEDICAL NECESSITY GUIDELINES

• Psychological or neuropsychological testing is limited to once per calendar year. More than one claim submission for testing per year may be subject to additional medical records and a medical necessity review.
• Psychological testing is not typically considered medically necessary if the individual is actively using impairing substances, is having acute withdrawal symptoms or has recently entered recovery, as testing results may be invalid.
• Standardized tests that are based on published, national, normative data with scoring resulting in standardized or scaled scores are required.
• Results are expected to provide specific value and data needed to develop or modify an individualized treatment plan when one or more of the following conditions are met:
  • ​​A DSM diagnosis is not achieved with existing data obtained through standard assessments to include the clinical interview, behavioral observations and/or consultations with other information sources and review of the member’s clinical history, or
  • Formulation of a working treatment plan would not be therapeutic nor meet the member’s needs without data that is only obtained via psychological testing, or
  • The member has not successfully responded to the treatment plan put forth, or
  • To further delineate between the differential diagnoses of a psychiatric or neurological/medical condition that may be affecting treatment outcomes.
• The proposed psychological tests are not primarily for educational purposes, including but not limited to poor academic performance, academic accommodations, evaluation of learning disabilities, determining grade placement, and Individual Education Plan (IEP) planning/assessment.
• The proposed psychological tests are not primarily for determination of job or occupational placement.
• The proposed psychological tests are not primarily for determination of disability claims and/or for court/legal purposes.
• The proposed psychological tests are targeted to answer specific questions that cannot be determined by a diagnostic interview, review of psychological/psychiatric records or a second opinion.

PRE-AUTHORIZATION PROCESS
Psychological testing may be an exclusion in some policies. Additionally, certain policies may exclude specific DSM diagnoses. Benefits and exclusions will be verified during the authorization process. If psychological testing is requested to evaluate these diagnoses, it will be a non-covered service.

Initial Psychological Testing Request must meet all of the following criteria for authorization:

1. The identified patient has a valid DSM/ICD-10 diagnosis or R/O diagnosis.
2. If the patient is referred for testing, the referral should be made by a licensed physician or licensed behavioral health practitioner.
3. The clinician administering or supervising administration of the test battery is fully licensed and credentialed, and the state licensing Board of his/her locale has determined that test administration, scoring and interpretation is within the individual’s scope of practice. In South Carolina, reimbursement for testing is limited to physicians and psychologists or supervising psychologists determined to be eligible by the South Carolina Board of Examiners in Psychology. Licensed Professional Counselors (LPC) are not authorized to perform psychological testing. Psychological testing requests from LPCs from other states will be evaluated on a case-by-case basis. Psychological testing for autism provided by licensed psychoeducational specialists (LPES) may be accepted for approval for autism benefits (see CAM 387 for guidance).
4. The testing request should list the requested CPT code(s) and related DSM diagnoses.
5. Claims should be submitted upon the completion of all testing related services rendered. This includes all activities related to pre-assessment planning, test administration, scoring, integration of data, and report write up. If testing takes place across multiple days, the claim should be submitted at the conclusion of all services.
6. Testing comprised solely of brief symptom inventories or screening tests (paper and pencil or computerized) does not qualify as comprehensive psychological testing. When indicated, these services may be billed using brief assessment or automated testing CPT codes.
7. CPT codes that are time based should not be billed concurrently with other time-based codes for the same service period. For example, if a provider is conducting a 60-minute therapy session and administers a Beck Depression Inventory during this session, the provider may bill a therapy code for the session along with a brief behavioral assessment code. The provider should not bill an additional half hour or one- hour duration testing CPT code since the time spent with the patient did not exceed 60 minutes.
8. Psychological and neuropsychological testing base codes may only be used once per testing episode. If testing takes place across multiple days, the base code should only be used once at the start of the service episode.
9. Providers performing comprehensive psychological or neuropsychological evaluations should not bill both psychological and neuropsychological evaluation codes for the same episode of service. Providers should decide whether the testing is predominantly psychological or neuropsychological and bill accordingly.
10. Psychological and neuropsychological testing CPT codes 96130-96133 , 96136-96139 should be billed when a provider is performing a comprehensive psychological or neuropsychological assessment. Unless followed by a comprehensive assessment, these codes should not be used when providing brief screenings or assessments to monitor patient progress during routine therapy sessions or psychiatric follow- up visits. CPT codes 96130-96133 may only be billed by a Qualified Healthcare Professional (QHP) who is independently licensed. Individuals who are working or training under the supervision of the QHP are considered technicians.

REFERENCES

1. American Medical Association. (2014). CPT 2014: Current Procedural Terminology, standard edition. Chicago: Author.
2. American Psychiatric Association. (2020). APA Guidelines for Psychological Assessment and Evaluation.  APA Council of Representatives, March 2020.
3. American Psychiatric Association. (2016).  Practice guideline for psychiatric evaluation of adults, third edition. In: American Psychiatric Association practice guidelines for the treatment of psychiatric disorders. Washington: American Psychiatric Association.
4. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders-5. Washington, DC: Author.
5. American Psychological Association (2018).  2019 Psychological Testing and Evaluation CPT Codes toolkit.  Available online at: https://www.apaservices.org/practice/reimbursement/health-codes/testing.html?_ga=2.232264095.1470466716.1547058736-2065150755.1547058736.  Last accessed January 9, 2019.
6. American Psychological Association (2006, January). 2006 testing codes toolkit. Available online at: http://www.apapractice.org/apo/toolkit.html#. Last accessed March 15, 2006.
7. Binder, L. M., Campbell, K. A. (2004). Medically unexplained symptoms and neuropsychological assessment. Journal of Clinical and Experimental Neuropsychology, 26 (3), 369-392.
8. Bornstein, R. (2016). Evidence-based psychological assessment. Journal of Personality Assessment, Nov 3: 1-11.
9. Clarkin, J., Hurt, S., & Mattis, S. (1994). Psychological and neuropsychological assessment. In R. Hales, S. Yudofsky & J. Talbot (Eds.), The Textbook of Psychiatry (2^nd ed., pp. 247-276). Washington, DC: American Psychiatric Press.
10. Feinberg, T. E., Roane, D. M., Miner, C. R., et al. (1995). Neuropsychiatric evaluation in an outpatient setting. Journal of Neuropsychiatry and Clinical Neurosciences, 7 (2), 145-154.
11. Howieson, D. & Lezack, M. (1997). The neuropsychological evaluation. In S. Yudofsky & R. Hales (Eds.), The American Psychiatric Press Textbook of Neuropsychiatry (pp. 181-204). Washington, DC: American Psychiatric Press.
12. Leahy, B. J. & Lam, C. S. (1998). Neuropsychological testing and functional outcome for individuals with traumatic brain injury. Brain Injury, 12 (12), 1025-1033.
13. Kahn, D. A., Carpenter, D., Docherty, J. P., & Frances, A. (1996). The expert consensus guideline series: treatment of bipolar disorder. Journal of Clinical Psychiatry, 57, Suppl 12A.
14. McEvoy, J. P., Scheifler, P. L., & Frances, A. (1999). Treatment of schizophrenia 1999. The expert consensus guideline series. Journal of Clinical Psychiatry, 60, Suppl 11, 3-80.
15. Osview, F. (1997). Bedside neuropsychiatry. In S. Yudofsky & R. Hales (Eds.), The American Psychiatric Press Textbook of Neuropsychiatry (pp. 121-164). Washington, DC: American Psychiatric Press.
16. Pliszka, Steven (2007). Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder. Journal of the American Academy of Child and Adolescent Psychiatry (pp. 894-921), 46 (7).
17. Rao, S. (1996). Neuropsychological assessment. In B. Fogel & R. Schiffer (Eds.), Neuropsychiatry (pp 29-46). Baltimore: Williams & Wilkins.
18. Roback, H. & Welch, L. (2000). Psychological testing in psychiatry. In M. Ebert, P. Loosen & B. Nurcombe (Eds.), The Current Diagnosis and Treatment in Psychiatry (pp. 137-154). New York: Lange Medical Books/McGraw Hill.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community,  and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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