CPT Code 96130 and CPT Code 96138 - New CPT Codes for Psychological Testing
In 2019 CMS approved the use of a new set of psychological CPT codes and retired a set of existing CPT codes related to the same. It is important to understand the underlying spirit of what they were trying to accomplish with this decision in order to understand how these new codes are designed to be used.
In the past many healthcare organizations would administer tests and screening for mental health, but lacked the financial resources to actually treat mental health. There are countless examples of clinics collecting a PHQ-9, putting it into the patient’s chart, and not even reviewing the results until days or weeks later, if even at all.
In order to give healthcare organizations the ability to seriously deal with mental health a new approach was required. The new CPT codes are designed to provide clinics with the financial resources they need to take the mental health “bull-by-the-horns”.
For the purpose of this article we will be focusing on the new 2019 CPT codes that are relevant to certain computerized psychological testing. These CPT codes may be used with other forms of testing, including paper-based testing and interview-based testing.
There are 3 main categories of focus; screening, test administration, and test evaluation.
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.
CPT code 96127 (Brief emotional/behavioral assessment with scoring and documentation, per standardized instrument) has only been around since early 2015, and has been approved by the Center for Medicare & Medicaid Services (CMS) and is reimbursed by major insurance companies, such as Aetna, Anthem, Cigna, Humana, United Healthcare, Medicare and others.
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”/ must be justified by a related ICD-10 code. Test administration can be performed by either a physician/ qualified healthcare professional, a technician under the supervision of a physician/ qualified healthcare professional, or a computer.
CPT code 96136 is used when tests are administered by a physician or other qualified healthcare professional and is defined as “Psychological or neuropsychological test administration/scoring by physician or other qualified healthcare professional, two or more tests, any method; first 30 minutes”. Note specifically that this code requires that at least 2 tests are administered and that they may be administered using any method. This could be paper, verbal, or electronic. Each additional 30 minutes would be billed using CPT 96137.
CPT 96138 is used when tests are administered by a technician and is defined as “Psychological or neuropsychological test administration/scoring by technician, two or more tests, any method; first 30 minutes”. Note specifically that this code requires that at least 2 tests are administered and that they may be administered using any method. This could be paper, verbal, or electronic. Each additional 30 minutes would be billed using CPT 96139.
CPT code 96146 is used when tests are administered by a computer and is defined as “Psychological or neuropsychological test administration, with single automated instrument via electronic platform, with automated result only”. Note specifically that this code is for use with a single automated instrument via electronic platform, with automated result only.
Test Evaluation Services:
Test evaluation services are designed to cover the physician/ qualified healthcare professional’s time in evaluating the results of a patient's mental health tests and determining a plan of action.
CPT 96130 is used by “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 specifically that this code requires documentation on the report, clinical decision making, treatment plan, and interactive feedback with the patient etc., when performed. Each additional 1 hour would be billed using CPT 96131.
With these new CPT codes in place there are new opportunities and incentives for healthcare organizations to make a measurable difference in their patient’s lives. By taking the time to deal with mental health, we will start to see not only an impact on the quality of lives of patients, but also a drastic reduction in the overall cost of medicine.