All right, y’all, today, we are talking all about billing for psychological and neuropsychological testing.
Now, you might say to yourself, Jeremy, why are we just now doing a billing episode? The new codes came out about 18 months ago. Isn’t this already settled?
I think as many of you probably know, if you’re billing insurance, the codes are far from settled. We are still engaged in active negotiations and appeals with multiple panels around the billing issues and why our claims aren’t going through. And I think this is the case for many of you who are billing insurance.
So I am going to dive in and cover a few areas here related to billing with [00:01:00] the 2019 updated codes. I’m going to start and just do a basic intro, outlining the codes, what they are, what to use them for. I’m going to talk about psychological testing versus neuropsychological testing. We’ll cover Medical Necessity. I did do an entire episode on Medical necessity that I’ll link in the show notes, but we’ll talk about it here as well. I will touch on navigating the limitations on hours, appeals, and resubmissions. I’m also going to talk through just a few weird ambiguous situations that I have seen popping up over the last several months in the Facebook group and in my coaching sessions and in our own practice.
So if those things are interesting to you or anything that you may have dealt with over the last several months, then you definitely want to stay tuned and check this one out.
Before I get to the episode, just a quick reminder that my [00:02:00] podcast team has doubled down over the last few months on podcast episodes. If you don’t want to miss an episode, please consider subscribing or following the podcast. You can do that easily in iTunes or Spotify. That way, you won’t miss any episodes coming up.
Okay, let’s talk about Insurance Billing.
All right, everybody. Let’s dive into the wonderful world of insurance billing for testing. For those of you who’ve been around for a while, you remember what we call the old codes. Now, the old codes were not easy to navigate necessarily, but [00:03:00] compared to the new codes which came out in January 2019, it was a complete cakewalk. I think a lot of you have probably experienced some difficulties with billing since the new codes were released in January 2019. And like I said, these issues have continued to persist in our practice. And I keep hearing comments on the Facebook group and in my coaching sessions from people who are just confused about billing with good reason.
So, the general theme here is that APA and CMS which is the entity linked to Medicare that dictates our billing practices were pretty clear initially about what these codes should look like, how to use them and how they should be paid. The way that that has played out in practice is completely variable. So the rules don’t really apply [00:04:00] in a lot of situations. And that has been super frustrating, by which I mean, many panels across the country are adopting their own standards and guidelines for how to implement these codes and how they’re going to pay these codes that don’t necessarily follow the rules and guidelines set out by CMS and APA, which naturally results in a lot of confusion and frustration and not getting paid on our part.
So, this has meant to demystify as much as I can. I will give a shout-out immediately to Dr. Tony Puente who is a past president of APA and really just the coding guru along with Dr. Neil Pliskin. They’ve done many webinars over the years on CPT codes and billing. You would be well-served to search out any resources that you can find from either of those guys. So, [00:05:00] a lot of the information that I’ll present to you is derived from their presentations and from the APA documentation on the new codes. So just to attribute the information appropriately.
All right, let’s dive into it.
So let’s start with the basics. When I say basics, I mean, just the codes themselves and what they should be used for. The big change as a lot of you probably know is that testing services got split up into two areas, compared to the old codes. So, the new code update split the testing process into administration and scoring, and then, everything else. Previously these two services were lumped together under the same codes which made things easier, but now they are separated and there are two separate [00:06:00] sets of codes for each of those services.
Let’s tackle the test administration and scoring first.
The codes that are associated with administration scoring are 96136, 96137, 96138, and 96139. I am going to use some shorthand throughout the rest of the episode. Instead of saying 96 before all of these codes, I’m just going to use the last three digits to save a little time and headache for all of us. So, as I said, 136 through 139 are the administration and scoring codes.
Now, the way that I think of this is just, these codes are truly meant to only capture literally administration and scoring of the tests. Now, everything else that you do in the evaluation process, except for the interview, [00:07:00] I will say that except for the diagnostic interview is going to be captured with the codes: 96130, 96121, 96132, and 96133.
And so when I say everything else, this includes test selection, record review, collateral interviews, or collaboration with physicians, clinical decision-making- which means switching up your battery on the fly based on what you’re seeing at the moment, it includes feedback sessions and it also includes report writing and integrating the data. So, you can really think of this again in two camps. There’s administration and scoring and then there’s everything else. That everything else is covered by 96130- 96133.
Let’s break those codes down a little bit further. When we say, administration and scoring, you notice that there are four codes, [00:08:00] 136, 137, 138, and 139. 136 and 137 are meant to capture time that is spent by the psychologists or what CMS calls a Qualified Health Professional or QHP. So 136 and 137 are the codes that capture time spent by the psychologist, by the licensed person with the contract with the insurance company administering and scoring the measures.
138 and 139 are what are called technician codes. Technician is another word for psychometrist or tech. There is currently no standardized definition of a technician. It varies from state to state, but Medicare does not have a standard definition of a technician. Generally, though, these individuals are either [00:09:00] unlicensed or they’re not doctoral-level clinicians. They do not have a contract with the insurance company and they are supervised by a qualified health professional, who is usually a psychologist. So again, 138 and 139 are technician codes.
Now, when you get to the other set of codes, 130 & 131 are psychological testing. 132 and 133 are for neuropsychological testing. I will cover the difference between those two in just a moment. Before I do that, I want to talk about one more set of codes and one single code that is out there.
So 96112 and 96113 are codes that are meant to capture developmental evaluation. When I say developmental evaluations, that really [00:10:00] means, at least the way that I interpret it, it’s meant to capture those younger kids who are not reaching developmental milestones appropriately and the testing that you’re doing is really meant to assess why that is happening and where their current developmental level is.
The single code I want to mention is 96146. And that is the code that is meant to capture a single automated instrument via an electronic platform. So these will be the tests that you administer over the computer that you don’t actually have to do anything during. You just set the computer and forget it and let the client complete that test.
Let’s talk about the other major change with the new codes, and that is the addition or specification of base codes and add-on codes and [00:11:00] that flows through to units and time allocated for each unit.
Previously, we would just bill the same code to capture the entire time that we spent testing and report writing and feedbacking, that’s a word, right? But now it’s broken down into base codes and add-on codes, and this applies to both the administration and scoring codes as well as the “everything else” codes.
So, let’s just take administration and scoring. In this case, 136, and 138 are the base codes. These are meant to capture the first half-hour of administration and scoring that you might spend. 137 and 139 are their respective add-on codes. And those codes are meant to capture each additional half-hour that you spend testing. So, if a psychologist [00:12:00] conducts 4 hours of testing, that would equal, one unit of 96136 to capture the first half-hour and 7 units of 96137 to capture the additional three and half hours. So remember that the administration and scoring codes are half-hour codes. So units are billed in half hours. That’s why we have one base unit and seven units to capture 4 hours. Confusing. Previously, it was all just hour codes and now, the administration and scoring codes are half-hour units.
Okay. So if you think about the “everything else” codes, these codes are hour codes. So one unit equals 60 minutes. The structure with the base code and the add-on system is parallel. So again, if a [00:13:00] neuropsychologist completed let’s just say 4 hours of feedback and report writing, he or she or they would bill one unit of 96132 as the base code and then three units of 96133 as the add-on code to capture those 4 hours of work. Same process if you were doing psychological testing, which uses 130 and 131.
So, just to do a little recap before I move on to the difference between psychological testing and neuropsychological testing, at least from a billing standpoint.
A little recap. Basically, the testing services were split into two sets of codes. There’s a set of codes for administration and scoring only, and then there is a set of codes for basically everything else: test selection, record review collateral interviews, clinical decision-making [00:14:00] feedback, report writing, and so forth. The codes were also broken down into base codes and add-on codes. So again, 136 and 138, 130 and 132 are the base codes. 137, 139, 131, and 133 are the add-on codes. I would also include… I keep forgetting honestly about 96112 and 96113, but they follow the same format. 112 is the base code 113 is the add-on code. And the last component, just to remind you again, is that the administration and scoring codes bill in half-hour units. So one unit equals 30 minutes, and everything else codes bill in 60-minute units. All of this is hopefully familiar to you.
Now, let’s talk about the difference at least from a [00:15:00] billing standpoint, between psychological testing and neuropsychological testing. Spoiler, this is unclear. There are folks out there, Dr. Antonio (Tony) Puente, is one who says that it’s a combination of CPT codes with ICD 10 diagnostic codes. The implicit message here is that medical diagnoses are more amenable to being billed as neuropsychological testing. But when I looked back at the documents and the guidelines that were originally set forth to distinguish psychological testing versus neuropsychological, it is a little muddy.
The language around neuropsychological testing uses… there are certainly more medical language when describing what neuropsychological testing might be. There’s a lot more reference [00:16:00] to medical conditions, the central nervous system, brain functioning, and so forth. But the main difference that I could tell at least language-wise is that descriptions of psychological testing really include a lot more language around mood and emotional and personality functioning than neuropsychological testing.
You might say, okay, that sounds easy. So then, psychological testing is just basically personality assessment and any measures that are specifically looking at mood and emotional functioning. However, the description for neuropsychological testing uses the word neuropsychiatric conditions quite a bit, or the phrase neuropsychiatric conditions. And to me, that’s blurry. So, are we talking about depression secondary to a medical condition [00:17:00] or anxiety secondary to changes in cognitive functioning, or is it just depression or just anxiety or just personality? So the distinction here is less clear, I think, than a lot of folks would like it to be.
Now, I will say that as far as tests administered and domains assessed, those are largely similar depending on whether you’re billing for psychological testing or neuropsychological testing. So in the documents that are available out there, there’s really no distinction that I could find that specifies certain measures are neuropsychological testing whereas certain other measures are only psychological testing. So it is tough to decide. And it really gets back to, I think the referral question and what you are trying to assess during your evaluation.
Now, I will [00:18:00] say that in our practice, the vast majority of evaluations we’re conducting fall under neuropsychological testing. So, this would be ADHD evaluations, anything looking at executive functions, memory, learning, attention and so forth.
Sorry, that that is less clear than maybe you would like it to be. Now, the one thing that I can provide clarity on is that guidelines are very clear that you should not be billing psychological testing and neuropsychological testing in the same evaluation. So the way that it’s phrased is that you should pick the set of codes that represents the predominant service being provided. So if the vast majority of your evaluation is looking at cognition, memory, executive functioning, that sort of thing, and then you do one personality test, that to me says that you are [00:19:00] billing for neuropsychological testing.
I would love to hear other opinions. This is, like I said, a gray area. If you would like to reach out and clarify that, I would welcome any of those clarifications, firstname.lastname@example.org.
All right, let’s talk a little bit about medical necessity. So, as I said, I did an entire episode on medical necessity and how to get pre-authorization for testing services from insurance panels. So I’m just going to dive in and do a little bit of a review here. Now, the documents that APA released back with the new codes did lay out quite a few circumstances that would dictate a medical necessity. Here are just a few.
Medical necessity is met when the evaluation is going to be used to aid in treatment planning, when it might be used to document [00:20:00] changes in cognition secondary to a medical condition or an event, when it might be used to measure cognitive or functional deficits that might help explain why kids aren’t acquiring knowledge or abilities at the same pace as their peers, to provide a differential diagnosis when a range of possible options exist and that differential diagnosis cannot simply be made with a clinical interview.
Now, that’s a major caveat for each of these factors for medical necessity that if you can answer any of these questions with a clinical interview, then medical necessity is not reached. So keep that in mind. But if you’re trying to make a differential diagnosis from a range of possible options that cannot happen during an interview, then you are in the territory of medical necessity. Also, it is considered medically necessary when you’re measuring symptoms in the context of medication effectiveness.[00:21:00] So those are just a few circumstances to keep in mind that might reach medical necessity. Now, I have found in at least my pre-authorization requests that it really helps to also have some evidence that the individual has pursued other means of treatment and they have not worked or that the individual has consulted other healthcare providers and they remain unclear about what’s going on with this person.
So you really have to show that you are answering a question that can not be answered either by someone else or solved with a medication trial, or that has been resistant to treatment. And these are just a few things that can help document medical necessity. No matter what you end up justifying or how you end up justifying the evaluation, [00:22:00] one big component is that you have to document everything. I’m not going to run down the entire list of what you’re supposed to document but the APA, again, this APA document that I will link in the show notes will give you quite a list. So, if you’re using an EHR, you can of course do this in the EHR, you can do this in a Google Doc, but just make sure to document everything that you are sending into the insurance panel. And even if you’re not requiring pre-authorization, the guidelines still say that you should document why your evaluation is medically necessary.
So, we’ve come up with a simple templated statement that we pop into the note using TextExpander, of course, if you did not hear the TextExpander episode, go back just a few and check that one out. [00:23:00] We use TextExpander and a short snippet to populate the comments section in our EHR for each appointment note that justifies and says why this evaluation was medically necessary.
All right. So let’s talk about just a bit navigating limitations on hours and then that flow through to appeals and resubmissions. So, here’s what we found out. With the new codes, we’re running into a lot more limitations on the hours or units that we can spend on an evaluation. Now, this is going to vary wildly across the country. The standards that were set forth originally said you’re going to need to document medical necessity for any testing that goes beyond 8 hours total. So that would be 9 hours including [00:24:00] the diagnostic interview. And that includes test administration and scoring as well as feedback and report writing and everything else.
We found that there are plenty of insurance panels who will reimburse more in the 12 to 14-hour range with very few problems, but generally speaking, we’ve definitely run into more limitations since the new codes came out. It seems like the vast majority of our panels will limit test administration and scoring to 12 units total. So 1 unit of the base code and then 11 units of the ad-on code. So, we get about six hours of test administration and scoring, and then the vast majority limits the “everything else” codes to about 8 hours. So again, one base code unit, and then seven [00:25:00] units of the add-on codes.
Now, I totally recognize that is very generous. In some parts of the country, in some panels, they’re very limited. So I just want to acknowledge that. But know that having limitations on your hours is probably going to be happening. Now, some ways that you can get around that if you feel that it’s medically necessary, of course, is, a lot of panels we have found, the limitations on the hours or the units are based on units billed per day and not necessarily total units billed for the evaluation. There are some of both, of course. So don’t quote me on this, but if you’re finding that you are running into limitations on units, you may try to break the testing up over multiple days [00:26:00] and see if you can bill for the full amount of time and bypass the restrictions on the units per day.
Let’s see. So this transitions nicely, I think, into appeals and resubmissions. So, every insurance panel has an appeal process. It is time-consuming and will not always go your direction, but this is where it gets back to the documentation that we were talking about just a little bit ago. If you have documented everything and can create templates for your appeals that tackle the common problems and why you are appealing those denials, that can help quite a bit. So, don’t hesitate to appeal. Don’t hesitate to resubmit. [00:27:00] My hope is that you will have some success with that process. Each insurance panel is going to have likely a different appeals process. It may be an online form. You may have to call. It may be a mailed form, but there will always be a process to appeal those evaluation denials.
Okay. So let’s talk about ambiguities and just weird situations that have come up that we’ve encountered and that I’ve seen in the Facebook group and my coaching sessions.
One big question is whether you have to wait until the end of the evaluation to bill or if you can bill as you go.
So originally the guidelines from APA and CMS said, wait till the end and bill it all on the same claim. That sounds great but it’s not feasible for a lot of people just from a revenue management standpoint. [00:28:00] If you’re waiting until the end of the evaluation every time to bill, that’s a long time to wait to get paid. So, plenty of folks are billing along the way. What I found has worked for our practice and many others are: submitting a claim for the intake note only, submitting a claim with the testing and administration codes, and then submitting one claim for the “everything else” codes that contains the units for the feedback session and the report writing and the collateral interviews and so forth. So, we typically submit three claims for each of those points of contact throughout the evaluation.
Now, I did read some documents that said that this method which they call drop billing is fine if you feel there’s going to be a delay between say the intake and wrapping up the evaluation or the [00:29:00] testing day and wrapping up the evaluation. So, it seems like it is fine.
Now, another question that’s related to this is, do you just bill one base code or do you use the same base code on multiple days if testing occurs across multiple days?
The question here is like, let’s say that you do 3 hours of testing on two separate days. Do you bill 96136 once as the base code and then 11 units of 96137 or do you do know one unit of 96136 and five units of 96137, and then another one unit of 96136 and five units of 96137? I found that both work but it depends on the panel. [00:30:00] So it always depends on the panel.
A good approach with all of this is do your best and if your best doesn’t work, try something different. And don’t be afraid to contact your provider rep and ask them directly what they want. That’s not always going to get you very far. We’re currently locked in a truly ridiculous discussion with Optum where they seemingly cannot tell us how to bill for these services. They have no idea how to bill for the services, and it’s been an ongoing process over the last six months or so.
That leads me to one of the other exceptions here. There are going to be outlying insurance companies that do things differently and if you haven’t already, you’re going to need to contact each of them. Like if you find yourself kind of running into a wall over and over for the [00:31:00] same issue and you just can’t figure it out, that panel may be an outlier and they may have some unique process that they want that may not follow the rules which is a very, very frustrating circumstance here. But that’s where you want to jump on and talk to the provider rep, talk to multiple provider reps if you can and claims reps, and get sort of an aggregate opinion about how exactly to bill to make sure that things are reimbursed.
Let’s see. Other weird situations that I have encountered, I’ve heard people report on problems billing psychometrist codes and psychologist testing codes on the same day. It is totally fine, and that was written into the guidelines that there will likely be [00:32:00] administration and scoring by a psychologist and a technician on the same day, but you’d likely have to use a modifier.
If the client leaves the office between sessions, let’s say they start testing in the morning with a tech, they go to lunch out of the office and come back to the office for an afternoon session with the psychologist, then you would use the XE modifier for that second session that occurred on the same day. If they don’t leave the office, but they just flow through into a separate testing session with either the psychometrist or the psychologist, then you would use the 59 modifier.
Other strange situations. Blue Cross Blue Shield in Colorado still has not added 96138 and 96139 to their fee schedule 18 [00:33:00] months later, despite all of our appeals and providing documentation about CMS guidelines. They just refuse to put 96138 and 96139 on the fee schedule.
So, these are just a few examples. There are weird situations happening out there where insurance panels are not following the guidelines set forth by CMS and APA about billing these new codes. If you’re running into trouble, you’re not alone. Don’t panic. Call your provider rep. Try to get multiple opinions about the best way to do it, and don’t be afraid to experiment with billing different sets of units, different limitations of units and so forth, different days all on one claim, that sort of thing to try to get these paid.
Now, I totally acknowledged that [00:34:00] while you’re doing this experiment, money is not getting paid and that truly sucks. So it’s been a rough road for a lot of us over the last 18 months or so with the new testing codes.
Let me see. Another situation that you may want to be aware of is, if you’re getting rejections for psychological testing, you may reconsider whether you can bill for neuropsychological testing or vice versa. I know some panels that will reject one set of codes or the other without a pre-authorization or they might require a pre-authorization for some codes, but not others. So like I said, think outside the box, really take a look at how you’re billing and if there are any alterations that you can legally and ethically make that [00:35:00] may help your case.
All right. So this was a whirlwind tour of billing for psychological testing and neuropsychological testing. Check out the show notes. There will be some resources, of course, in there for things that I mentioned here during the episode. And if you have not subscribed to the podcast, I would love for you to do that and make sure you don’t miss any episodes coming up.
I’ll be wrapping up the insurance mini-series next week with how to request raises from insurance panels. And then we’ll be launching into a series around a beginner practice and all of the nuances of that process.
All right. I hope you all are doing well and taking care of those, you know, I know a lot of folks are on the West Coast and just keeping in mind everything that’s going on over there with the fires [00:36:00] and whatnot. 2020 is really just punching all of us in the face, some of us harder than others. So hang in there and take care of everybody.
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