Billing and payment

Medicare covers psychological and neuropsychological test administration whether it is performed by the professional, by a technician, or by a computer. The codes for test administration by a professional (codes 96136, 96137) and by a technician (codes 96138, 96139) are billed in 30-minute increments. The computer testing code has a flat rate of reimbursement, meaning the payment amount is the same no matter how many hours the testing takes (code 96146).

The professional codes for psychological and neuropsychological testing evaluation services can also be used to reflect time spent integrating clinical data and patient information from other sources to produce a comprehensive report. Medicare also reimburses mental health professionals for furnishing a neurobehavioral status examination (codes 96116, 96121).

Medicare covers services for the assessment of aphasia (code 96105), developmental screening/testing (96110, 96112, 96113), cognitive performance testing (code 96125), and brief emotional/behavioral assessment (code 96127).

Please refer to APA’s Psychological and neuropsychological testing billing and coding guide for a detailed description of the structure, function, and utilization of this code set.

Health behavior assessment and intervention services are used to identify and address the psychological, behavioral, emotional, cognitive, and interpersonal factors important to the assessment, treatment, or management of physical health problems. The patient’s primary diagnosis is physical in nature and the focus of the assessment and intervention is on factors complicating medical conditions and treatments.

These codes describe assessments and interventions to improve the patient’s health and well-being by utilizing psychological and/or psychosocial interventions by a qualified health provider designed to ameliorate specific disease-related problems. These services can be provided in person, through telehealth, and by audio-only appointments.

Because the patient’s diagnosis must be physical in nature, the claim form must include a primary ICD-10 diagnosis code associated with their physical condition, not a DSM diagnosis of a mental health condition. Health behavior assessment or reassessment (code 96156) includes evaluation of the patient’s responses to disease, illness or injury, outlook, coping strategies, motivation, and adherence to medical treatment. Assessment is conducted through health-focused clinical interviews, observation, and clinical decision making. This is a standalone service; therefore, only a single unit of code 96156 should be reported on the claim form.

Health behavior interventions are provided individually (96158, 96159), to a group (96164, 96165), or to the family, with (96167, 96168) or without (96170, 96171) the patient present, and includes promotion of functional improvement, minimizing psychological and/or psychosocial barriers to recovery, and management of and improved coping with medical conditions.

Health behavior intervention services are time-based and are reported using a base/add-on code pair. The base code is reported for the initial 30 minutes of time spent performing the intervention, and add-on codes are reported for each additional 15-minute increment of time needed to complete the service. For example, a psychologist providing 45 minutes of health behavior intervention to an individual patient would report 1 unit of code 96158, for the initial 30 minutes, and 1 unit of code 96159, for the additional 15 minutes of service. When the service falls between units for the 15-minute add-on code, the psychologist must provide at least 8 minutes of the service in order to report an additional unit.

Please refer to APA’s Health behavior assessment and intervention services page for a detailed description of the structure, function, and utilization of this code set.

When billing Medicare, psychologists must include a code to indicate the location, known as the place of service (POS), where the service was delivered. The most commonly used POS for outpatient services is number 11 (office). View a list of the POS codes on the Centers for Medicare and Medicaid Services (CMS) websiteopens in new window.

Medicare claims submitted electronically in the format mandated by the Health Insurance Portability and Accountability Act (HIPAA) Transaction Rule are paid more quickly than those that are not.

HIPAA-compliant electronic claims will be eligible for payment 14 days after they are received. Noncompliant electronic claims, along with paper claims, will be eligible for payment 27 days after they are received.

Since October 2003, health professionals and other entities covered under the HIPAA Transaction Rule have been required to submit Medicare claims using a standardized electronic format. Among the exceptions to the rule: Practices with 10 or fewer full-time employees are not required to file Medicare claims electronically.

CMS implemented a “contingency plan” allowing covered entities to file noncompliant claims after the October 2003 deadline. Under the CMS contingency plan, noncompliant electronic claims were eligible for payment 14 days after they were received. The agency has modified its plan, however, to begin treating noncompliant electronic claims as though they were paper claims—thereby facing an additional 13-day time lag in eligibility for payment compared to HIPAA-compliant electronic claims.

For additional information about the HIPAA Transaction Rule, please visit the HIPAA compliance page.

Procedure-to-procedure

Procedure-to-procedure (PTP) edits, also known as Column 1/Column 2 edits, prevent improper payment when incorrect code combinations are reported. Many of the NCCI edits are based on the standards of practice. These files contain two columns of codes: The code in Column 1 is the service that is eligible for payment, while the code in Column 2 is not eligible for payment if reported by the same provider, for the same patient, on the same date of service (unless an exception is met).

However, there are instances when PTP edits can be overridden by appropriate use of a modifier. For more information on please refer to the CMS Proper Use of Modifiers 59, XE, XP, XS, and XUopens in new window (MLN1783722).

Medically unlikely edits

Medically unlikely edits (MUEs) were developed by CMS to reduce its contractors’ error rate on paid Medicare Part B claims. An MUE for a CPT code is the maximum units of service that a provider would report—under most circumstances—for a single beneficiary on a single date of service.

Add-on codes edits

An add-on code (AOC) is a CPT code that describes a service that is performed in conjunction with the primary service by the same practitioner. An AOC is rarely eligible for payment if it’s the only procedure reported by a practitioner.

NCCI edit updates are published every quarter and are available on the CMS Medicare NCCI edits webpageopens in new window. We also encourage you to review the CMS How to Use the Medicare NCCI toolsopens in new window to better understand how to utilize the NCCI files.