Optum adopts APA’s guide on billing for testing services

In September, the nation’s largest managed behavioral health care organization announced that it will adopt APA’s 2019 Psychological and Neuropsychological Testing Billing and Coding Guide as guidance on the clinical criteria it will use to make coverage decisions about testing services. Optum, which provides behavioral health care to 34.5 million Americans, will put the new policy into effect January 1, 2021.

By adopting the guide, Optum has decided to let the experts—psychologists and neuropsychologists—have their say on which psychological and neuropsychological testing services should be covered. That’s good news for psychologists and their patients, says Stephen Gillaspy, PhD, senior director of APA’s Office of Health Care Financing. “It’s really important that insurance companies don’t set those standards but that you have clinicians and medical societies like APA being able to weigh in on issues like when the services we provide are medically necessary,” says Gillaspy.

Developed by APA’s Testing Advisory Group and APA Services, Inc. staff, the guide was a response to the new psychological and neuropsychological testing CPT^® codes that went into effect in 2019. To help both commercial and government payers as well as providers navigate those changes, the guide serves as a blueprint for developing billing and coding policies, claims adjudication processes, and the production of educational resources. The guide:

• Describes the new codes
• Provides guidance on how to document services and bill for services, including those that take place over multiple days
• Offers specifics about coverage indications, limitations of coverage, and medical necessity

The final section features the scientific evidence that supports the guide’s recommendations and additional educational resources.

A billing and coding guide addendum (PDF, 327KB) provides three examples of how to code, document, and bill for testing services. Based on the most common concerns reported by APA members since the new codes went into effect, the examples walk users through entire episodes of care, including selecting a test, interviewing the patient, administering and scoring the test, writing a report, and giving feedback to the patient, family, and referring physician.

APA has also sent the guide to several other national companies, hoping that they will adopt it, too. In addition to promoting best practices on testing coverage, APA’s goal is to make billing and coding policies for testing as consistent as possible, no matter who’s paying for the services. Insurers, for example, have different policies on billing for testing services that take place over multiple days.

“For most medical billing with base and add-on codes, everything takes place on the same day, but for testing, you evaluate the person one day, look at the test results another day, and then discuss the results on another,” notes Alan Nessman, JD, senior special counsel for legal and regulatory affairs at APA. “This question of billing over multiple days was probably the biggest source of confusion and differing company policies: Some insurers want you to submit a separate bill for each day of testing instead of submitting one bill at the end that covers all the dates of services. And that affects your use of base and add-on codes.”

To encourage consistency, APA’s guide suggests best practices—in this case, to report all services once the testing process is complete, using base and add-on codes to capture the entire testing process from start to finish. “For a big company like Optum to adopt our recommendations for using these codes, it’s just great in terms of best practices being adopted,” says Nessman.

Such consistency isn’t just an administrative matter, adds Gillaspy. It can also improve patient care by allowing psychologists and neuropsychologists to focus on their actual work, he says.

“We want to have as much consistency across payers as possible so that providers are able to just do their clinical work without trying to figure out what they can and can’t do based on payment policies,” he says. “When the rules are different, every time a patient walks in the door, it’s a challenge to just provide the top-notch clinical care you want to provide.”

If you are having a billing, coding or reimbursement issue with one or more of your payers, please contact your state psychological association or contact staff experts at APA.