I would start your review of coverage for the services in question by pulling for the Medicare carrier you bill the following local coverage determination policy, if your MAC has a policy as below. Additionally you look at the private carrier's policies regarding coverage. The reason it is important is as seen below for example from WPS Medicare there are specific requirements on who can administer the test and who can provide the interpretation and report. This needs to be shared with those you are reviewing the coverage for this, for your particular Medicare carrier's LCD. And potential commercial carrier's policy if you are able to locate for these carriers. These limitations can help better understanding coverage for these services.
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WPS Medicare J5
Psychological and Neuropsychological Testing (L31990)
Indications and Limitations of Coverage and/or Medical Necessity
Psychological testing
CPT codes 96101, 96102, 96103, 96105, 96111
Psychological tests are used to assess a variety of mental abilities and attributes, including Central Nervous System (CNS) Assessments such as neuro-cognitive, mental status, achievement and ability, personality, and neurological functioning.
Psychological testing requires a clinically trained examiner. All psychological tests should be administered, scored, and interpreted by a trained professional such as a clinical psychologist, psychologist, advanced nurse practitioner with education in this area or a physician assistant who works with a psychiatrist with expertise in the appropriate area. The purpose of psychological testing includes the following:
1. To assist with diagnosis and management following clinical evaluation when a mental illness or psychological abnormality is suspected.
2. To provide a differential diagnosis from a range of neurological/psychological disorders that present with similar constellations of symptoms, e.g., differentiation between pseudodementia and depression.
3. To determine the clinical and functional significance of a brain abnormality.
4. To delineate the specific cognitive basis of functional complaints
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Below is the lay description of the services in review by Optum Encoder. Additionally is each of the codes with their descriptors. It is noted that 96101 requires face-to face administration by psychologist or physician. CPT 96102 requires technician administer the test and qualified health care professional to interpret the and provide a report. This is also where the LCD would need to be review on who is considered a qualified health professional for this type of interpretation and report. For 96103, describes a service administered by a computer, with qualified health care professional interpretation and report.
_______________________________________________________________ Lay Description by Optum Encoder
The physician or psychologist administers and interprets the results of psychological testing. The testing in written, oral, computer, or combined formats measures personality, emotions, intellectual functioning, and psychopathology. Code 96101 applies to each hour of testing and includes both face-to-face time administering tests to the patient, as well as interpretation and preparation of the report; however, it is not used to report the interpretation of technician- or computer-administered tests. In 96102, a technician administers the test, which is interpreted and reported by a qualified health care professional. In 96103, the test is administered by computer, which is interpreted and reported by a qualified health care professional.
96101 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI, Rorschach, WAIS), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report
96102 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI and WAIS), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face
96103 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI), administered by a computer, with qualified health care professional interpretation and report
