Reimbursement

Prepared by: Fati Davoudi, Director.
Date Issued: Jan 5, 2014.

Cognistat has compiled the following information from clients and third party sources for your convenience.  All content on this document is informational only, general in nature, and does not cover all situations or all payers’ rules and policies.  Please consult the disclaimer section.

Reimbursement Procedure Codes for Neuro-cognitive Testing

The American Medical Association (AMA) and the Center for Medical Services (CMS) are the governing agencies that generally set the procedure codes and how they are used.  Regional or local insurance companies such as Medicare third party administrators, Blue Cross/Shield or large national carriers generally follow these rules but there can be regional differences or variances in both fees paid and utilization procedures. 

Even though the patient may not qualify for Medicare most payers design their coverage rules according to CMS criteria.  The value of neuro-cognitive testing is well recognized and CMS has sent out several memos mandating coverage for these codes.

Reimbursement guidelines allow for billing both HOW the test was administered and for INTEGRATING the testing results and there is extensive reimbursement coverage for these procedures.   The main reimbursement codes that cover Cognistat are:

Psychological testing, codes 96101, 96102, and 96103

Neuropsychological or neuro-cognitive testing procedures, codes 96116, 96118, 96119, and 96120

Psychological testing helps evaluate the general psychological status (symptoms) and processes e.g., behavioral, emotional, etc. Neuropsychological / neurocognitive testing generally involves psychometric assessment of neurophysiological domains derived generally from standardized, objective and quantitative results.  The information generated from medical and mental health assessment scales and the selected neurocognitive tests can be compiled and integrated with data from other sources into a more comprehensive report (96101, 96118).

Matching CPT Codes with ICD or DSM Codes and Modifiers

Coverage for neuro-cognitive procedures can vary and either be covered for neurological or psychological conditions. The relevant ICD and/or DSM code should also be applied and those ICD and DSM codes can also vary from plan to plan. In addition to the appropriate codes there may be additional modifiers that can be submitted to insurers.  Modifier 25, 59 and 52 are the most common modifiers used. The use and need of modifiers may vary so consultation with payers and carriers for definitive guidance on their policies is recommended.

Who can Perform and Bill the Assessment?

CMS guidance states “…regulations allow a clinical psychologist (CP) or a physician to perform the general supervision assigned to …psychological and neuropsychological tests. In addition, nonphysician practitioners such as nurse practitioners (NPs), clinical nurse specialists (CNSs) and physician assistants (PAs) who personally perform …psychological and neuropsychological tests are excluded from having to perform these tests under the general supervision of a physician or a CP. Rather, NPs and CNSs must perform such tests under the requirements of their respective benefit instead of the requirements for psychological and neuropsychological tests. 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. Furthermore, physical therapists (PTs), occupational therapists (OTs) and speech language pathologists (SLPs) are authorized to bill three test codes as “sometimes therapy” codes. Specifically, CPT codes 96105, and 96111 may be performed by these therapists. However, when PTs, OTs and SLPs perform these tests, they must be performed under the general supervision of a physician or a CP.” NOTE: Each carrier/payer may have different testing and billing guidelines.

CMS Frequently Asked Questions

NeuroPsych and Neurological Codes

96116  Testing & Interpretation (Estimated National Average Reimbursement $95)

Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, e.g., acquired knowledge, attention, language, memory, planning and problem Striving, and visual spatial abilities), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report.

96118  Testing & Interpretation (Estimated National Average Reimbursement $99)

Neuropsychological testing (e.g., Cognistat, Halstead - Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), per hour of the qualified healthcare professional time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report.

96118  Additional Professional  (Estimated National Average Reimbursement $99)

96118 is also used in those circumstances when additional time is necessary to integrate other sources of clinical data, including previously completed and reported technician- and computer-administered tests.

IMPORTANT (Do not report 96118 for the interpretation and report of 96119 or 96120)

96119  Testing & Interpretation  (Estimated National Average Reimbursement $81)

Neuropsychological testing (e.g. Cognistat, Halstead - Reitan Neuropsychological Battery,
Wechsler Memory Scales, and Wisconsin Card Sorting Test), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face.

96120  Testing & Interpretation (Estimated National Average Reimbursement $48)

Neuropsychological testing (e.g. Cognistat, Wisconsin Card Sorting Test), administered by a computer, with qualified health care professional interpretation and report.

http://www.cdc.gov/NCBDDD/autism/documents/AAP-Coding-Fact-Sheet-for-Pri...

96101 Testing & Interpretation (Estimated National Average Reimbursement $81)

Psychological testing (includes psych assessment of emotionality, intellectual abilities, cognition, personality and psychopathology, e.g., MMPI, Cognistat, Rorschach, WAIS), per hour of the qualified healthcare professional time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report.

96101 Additional Professional (Estimated National Average Reimbursement $81)

96101 is also used in those circumstances when additional time is necessary to integrate other sources of clinical data, including previously completed and reported technician and computer administered tests.
IMPORTANT (Do not report 96101 for the interpretation and report of 95102, 96103)

96102 Testing & Interpretation (Estimated National Average Reimbursement $66)

Psychological testing (includes psych assessment of emotionality, intellectual abilities, cognition, personality and psychopathology. e.g., Cognistat, MMPI, and WAISI), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face.

96103 Testing & Interpretation (Estimated National Average Reimbursement $28)

Psychological testing (includes psych assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., Cognistat, MMPI), administered by a computer, with qualified health care professional interpretation and report.

90791 (Formerly 90801) Psychiatric evaluation exam (no medical services - Non-Prescriber.) (Estimated National Average Reimbursement $134)
For the elicitation of 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.

90792 (Formerly 90801) Psychiatric evaluation exam (no medical services - Prescriber.) (Estimated National Average Reimbursement $144)
For the elicitation of 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.

Reimbursement Documentation:

CMS (Recovery audit program) and other payers have active and ongoing audit programs to recover fraudulent claims.  Clients have expressed the following tips to help a practice be prepared for an audit.

Technical Component – Label whether Tech admin or Computer admin, Number of Tests.
Professional Component – Label Activities: Testing by Professional, Interpretation,
Report, or Integration of findings which may include history, prior records, interview(s), and
compilation of tests.

COGNISTAT ASSESSMENT contains an automatic Time and Date stamps.  For  the Paper and Pencil testing minimum documentation should be: Date(s) & Total Time Elapsed, Maximum: Date(s) Start and Stop Times; Testing Time Backup ‐ Scheduling System (e.g., schedule book; agenda, etc.), Testing Sheet with Lists of Tests with Start/Stop Times, Keep Time Information as long as records are kept. *Medical Necessity can vary by Payer.

Disclaimer

The information provided in this document was obtained from third‐party sources and is subject to change without notice as a result of changes in reimbursement laws, regulations, rules, and policies.  All content on this document is informational only, general in nature, and does not cover all situations or all payers’ rules and policies. This content is not intended to instruct medical providers on how to use or bill for healthcare procedures, including new technologies outside of Medicare national guidelines.

Clinicians and healthcare providers should consult with their billing office to determine the code or the mixture of codes that will work best for screening and providing mental health services.

You may share this information with various health plans to see if they accept the codes in this guide and to inquire about whether they provide payment for mental health screening and, if so, to clarify with which code(s) should be used.

A determination of medical necessity is a prerequisite that Cognistat assumes will have been made prior to assigning codes or requesting payments. Medical providers should consult with appropriate payers, including Medicare fiscal intermediaries and carriers, for specific information on proper coding, billing, and payment levels for healthcare procedures. This information represents no promise or guarantee by Cognistat concerning coverage, coding, billing, and payment levels. Cognistat specifically disclaims liability or responsibility for the results or consequences of any actions taken in reliance on this information.