Mental health is increasingly recognized as a dynamic and integral aspect of overall wellbeing. Globally, 1 in every 8 people live with a mental disorder, with conditions such as schizophrenia, depression, Alzheimer's, dementia, ADHD, post-traumatic stress disorder (PTSD), and autism profoundly contributing to rising disability rates in the United States (WHO, 2022; U.S. Burden of Disease Collaborators, 2013). This revelation underscores the need for greater attention to mental health in healthcare systems.

While advancements in neuroscience have contributed significantly to mental health and cognitive wellbeing, much progress remains. 

To further elevate the effectiveness of interventions, it is important to consider integrating cognitive neuroscience with mental health care. Utilizing this interdisciplinary approach allows for the development of more targeted, evidence-based treatments that not only improve patient outcomes but also enhance recovery rates and reshape the future of mental health care. 

By bridging these fields, we can unlock new potential for addressing complex mental health challenges with greater precision and impact (Wojtalik et al., 2018; Matto & Strolin-Goltzman, 2010).

In this article, we discuss how to differentiate psychological and neuropsychological evaluations, including best practices and clinical examples.

Coding Psychological and Neuropsychological Evaluations

To understand the potential underlying implications of a cognitive disorder or impairment, neuropsychological or psychological tests are typically ordered for patients experiencing memory or behavioral difficulties to correlate these issues with specific brain areas. 

For example, a psychiatrist might order a test to assess behavioral or emotional disorders, while a neurologist might administer one for patients with conditions like cerebrovascular disease, dementia, or epilepsy with cognitive involvement. 

Qualified Healthcare Providers (QHPs) might also conduct tests for individuals with known or suspected brain damage or dysfunction. These tests help identify suitable treatment options, monitor treatment progress, and predict recovery from neuropsychological or psychological conditions.

For reporting psychological or neuropsychological testing evaluation, determine the correct coding utilizing one of these primary CPT codes:

• CPT 96130 - Psychological testing evaluation services by physician or other qualified healthcare professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour.
• CPT 96132 - Neuropsychological testing evaluation services by physician or other qualified healthcare professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour.

Time-Based and Add-On Coding Specifics

Both codes 96130 and 96132 are billed on an hourly basis, with add-on codes +96131 and +96133 applicable for each additional hour increment. 

It is essential to understand that a minimum time threshold must be met to report these services. For example, following the midpoint rule, the service becomes reportable once the duration exceeds half the time increment; specifically, this means 31 minutes or more for the primary codes and 91 minutes or more for the add-on codes.

An important exception to this rule is that if the time spent exceeds 31 minutes on a subsequent service date, providers can still utilize the add-on codes +96131 or +96133 without needing to meet the 91-minute threshold on this date.

Who Can Perform These Services?

A physician or psychologist is not always required to administer or supervise neuropsychological tests. In cases where a non-physician Qualified Healthcare Professional (QHP)—such as a Nurse Practitioner (NP), Clinical Nurse Specialist (CNS), or Physician Assistant (PA)—conducts the testing, CPT codes 96130–96133 can still be applied, provided their scope of practice allows it under state laws.

According to the Centers for Medicare & Medicaid Services (CMS), incident-to-billing criteria for psychological and neuropsychological evaluation and testing services differ.

CMS outlines a regulatory exception for these services, specifying that "…for diagnostic psychological and neuropsychological tests, there is a regulatory exception that allows either a clinical psychologist (CP) or physician to perform the assigned general supervision." This means QHPs can personally perform these services under their benefit, provided they are under the general supervision of a CP, MD, or DO (when required by their state regulations) without restriction (CMS, 2024). 

 General Supervision:

• General supervision refers to a service being performed under the overall direction and control of a physician, but without the physician being physically present during the procedure. Under this level of supervision, the physician is responsible for overseeing the training of non-physician personnel performing the diagnostic procedure and ensuring the proper maintenance of equipment and supplies.
• Documentation in the medical record must clearly indicate the point of transition to general supervision, although the format and method of this documentation are at the discretion of the supervising practitioner.

Medicare Reimbursement Considerations:

• Medicare does not reimburse services represented by CPT codes 96130/96132 when they are performed by students or trainees. However, the presence of a student or trainee during test administration does not disqualify a qualified healthcare professional from reporting and receiving payment for the testing, as long as the QHP maintains responsibility for the service.

Payer-Specific Restrictions:

• Individual payers may have their own criteria regarding which providers are eligible for reimbursement for neuropsychological testing services. These requirements may differ from CMS guidelines, so it is advised to carefully review payer-specific policies before submitting claims to ensure compliance with both documentation and coding standards.

By adhering to CMS regulations and carefully reviewing payer-specific guidelines, healthcare professionals can ensure accurate billing and avoid potential reimbursement issues.

Neuropsychological and Psychological Evaluation Stages

Neuropsychological and psychological evaluations, much like Evaluation and Management (E/M) services, involve a structured and methodical approach to assessing cognitive, emotional, and behavioral conditions. 

These assessments incorporate both face-to-face and non-face-to-face components, requiring a combination of clinical expertise, comprehensive evaluation, and precise documentation to ensure accurate diagnosis, proper reporting, and appropriate reimbursement.

Following the APA model, there are five distinct stages in each episode of care, although individual practice patterns may vary, and not all psychologists, neuropsychologists, or other qualified healthcare providers (QHPs) adhere to the exact sequence outlined in this model.

Five Stages in Clinical Decision-Making Care Episodes

• Pre-Service Work (Non-Face-to-Face Services)

• Reviewing records and clarifying referral questions
• Selection of tests

• Intra-Service Work (Face-to-Face Services)

• Conducting neurobehavioral status examinations
• Adjusting initial test selection based on clinical interview findings
• Administering tests (and scoring when manually performed):
  • Option A: Administered by a professional
  • Option B: Administered by a technician
  • Option C: Administered unsupervised (not separately reportable)

• Integration of Findings and Report Generation

• Integrating findings and generating reports

• Conducting Feedback Sessions (Face-to-Face Services)

• Conducting feedback sessions with the patient (and family/caregiver)
• Providing feedback to the referring physician

• Post-Service Work (Non-Face-to-Face Services)

• Report transcription
• Report distribution
• Coordination of referrals

These evaluation steps are integral to the overall service. Crucial activities may include reviewing medical history, selecting suitable assessments, documenting and interpreting test results, and formulating a treatment plan. Feedback is then provided to the patient or caregivers, ensuring a complete and transparent care process.

Importantly, these services are often performed alongside psychological or neuropsychological test administration (CPT codes 96136–96139, 96146). Evaluation services should always precede the test administration, with both billed together either on the same day or subsequent days, depending on the scheduling.

Differentiating Selection of Psychological vs. Neuropsychological Codes

When selecting the appropriate CPT code for evaluation services, it's essential to consider two main factors: the type of tests administered and the specialization of the provider or QHP conducting the evaluation and interpreting the results. Understanding these nuances is critical for ensuring accurate coding and proper reimbursement.

• Provider Specialization and Code Selection: Payers often distinguish between psychological and neuropsychological testing codes based on the specialization of the provider performing the evaluation. The following guidelines are commonly used to differentiate the appropriate codes:
  • CPT 96130: This code is typically used for psychological testing services, which may be conducted by providers such as psychiatrists, clinical psychologists, or other QHPs trained in psychological assessments. These evaluations focus primarily on psychological conditions and behavioral functioning.
  • CPT 96132: This code is designated for neuropsychological testing services, which may be carried out by neurologists, neuropsychologists, or QHPs with specialized training in neurological and cognitive evaluations. These services assess a broader range of functions, including both psychological and neurological regions.
• Test Type and Code Selection: In addition to provider qualifications, payers may differentiate between CPT codes 96130 and 96132 based on the type of testing administered. This distinction ensures that the scope and complexity of the evaluation are accurately represented in the billing process:
  • CPT 96130: Psychological testing focuses on emotional, behavioral, and cognitive assessments related to mental health conditions. This may include assessments for conditions such as depression, anxiety, personality disorders, or other psychiatric disorders. The testing primarily addresses psychological domains and is often used in clinical, counseling, or educational settings.
  • CPT 96132: Neuropsychological testing is more comprehensive, evaluating not only psychological aspects but also cognitive and neurological functions. This includes assessments of memory, executive function, attention, motor skills, and other brain-related functions. Neurological testing is crucial for diagnosing conditions such as traumatic brain injury (TBI), dementia, stroke, or other neurocognitive disorders.
• Payer-Specific Guidelines: When selecting between psychological and neuropsychological codes, it is crucial to be aware that payers may have unique policies governing their use. For instance:
  • Some payers may limit the use of neuropsychological testing codes to providers with specialized training in neurology or neuropsychology, ensuring that only appropriately qualified professionals conduct these evaluations.
  • Other payers may require detailed documentation demonstrating the medical necessity of neuropsychological testing (CPT 96132) over psychological testing (CPT 96130), particularly when assessing complex neurological conditions.
• Considerations for Code Bundling and Service Separation: While both CPT codes 96130 and 96132 are designated for evaluation services, they serve distinct purposes—psychological testing versus neuropsychological testing—and payer-specific guidelines often determine their appropriate usage. To mitigate potential coding issues such as bundling or denials, it’s essential to:
  • Carefully document the specific type of evaluation performed, ensuring clarity on whether the service focused on psychological or neuropsychological domains.

• • When services involve both psychological and neuropsychological components, robust and precise documentation is critical to justify the selection of codes and to prevent payer challenges related to code bundling or overlapping services.

By ensuring the correct code is selected based on payer guidance, considering both the provider's specialization and the specific tests administered, practices can optimize reimbursement, avoid coding errors, and maintain compliance with payer guidelines.

Billing Considerations for Psychological and Neuropsychological Evaluation Services

• Consolidating Claims Across Multiple Visits: If the evaluation service spans multiple appointments, all related codes should be captured by date and service and submitted together on a single claim once the evaluation is complete. This approach ensures comprehensive documentation and reduces the risk of claim denials for incomplete submissions. 
  
  According to CPT Assistant (Dec 2019), "When a physician or other qualified health care professional evaluation and testing service is spread out over multiple visits, the total cumulative time spent performing each type of service in the evaluation process (i.e., clinical/diagnostic interview, testing evaluation services, and test administration and scoring) should be reported after the entire episode of care. The physician or other qualified healthcare professional should create one bill for all cumulative services detailed by separate dates of service and submit it on the final date of service (i.e., the day of the feedback session).”
• Base and Add-On Code Usage: For the initial unit of service, only the base evaluation code should be submitted (e.g., CPT 96130 or 96132). Add-on codes (e.g., CPT 96131 or 96133) should be utilized for additional services rendered during subsequent sessions that meet the 31-minute threshold or for any time reaching 91 minutes during the initial evaluation. This ensures an accurate representation of the services provided while avoiding overcoding.
  
  For follow-up feedback sessions conducted on separate days, the appropriate add-on codes should also be billed. These sessions may include time spent interpreting test results and discussing findings with the patient or caregiver, thereby ensuring that services are correctly documented and reimbursed for ongoing care.
• Proper Use of E/M Codes: Evaluation and management (E/M) codes (99202-99215) should not replace psychological and neuropsychological evaluation codes. However, they can be billed in conjunction if a significant and separately identifiable E/M service is performed. 
  
  In such cases, ensure the proper use of modifier 25, appended to the E/M service, to indicate that the E/M service was distinct from the evaluation. Documentation should clearly support the separation of time, medical decision making (MDM) and medical necessity of both services, and be readily available for payer review if required.

Documentation Best Practices for Billing and Reimbursement

Accurate, detailed documentation is essential to support all services billed, ensuring compliance and maximizing reimbursement opportunities. Each service, including time spent, procedures performed, and follow-up care provided, should be clearly documented to justify the services rendered, especially in the case of payer inquiries or audits.

When services span across multiple visits, precise documentation becomes even more crucial. Since these are time-based services, a thorough record not only validates non-face-to-face time spent but also ensures accurate calculation of total times, which is key for appropriate billing. It is highly recommended that each stage of service be documented within a structured table format in the report, aiding in clarity and completeness.

• For Testing Evaluation Services (96130-96133), the Physician or Qualified Healthcare Provider (QHP) must document and summarize the evaluation criteria within the report.
  
  
• For Test Administration and Scoring Services (96136-96139), clear documentation is also required, including attestation to supervision by the Physician, QHP, or Technician, as applicable.

All documentation should include comprehensive listings of dates and total times for each activity, supported by a separate log sheet detailing start and stop times in the clinical chart. This level of detail is vital for demonstrating the medical necessity of services and securing accurate reimbursement. 

Clinical Example

Consider a 67-year-old female presenting to her physician with a six-month history of memory impairment, agitation, irritability, and uncooperative behavior. An initial screening, using the Creyos MCI screener, indicated the need for further evaluation, leading to an order for neuropsychological testing via the MCI protocol, using the Creyos platform to assess for Mild Cognitive Impairment (MCI). 

The patient returned the following week, where the assessment was administered by a technician under supervision, with a total administration time of 25 minutes. On the same day, the provider reviewed the patient's medical history, discussed the testing process with her, and completed the test selection and account setup. Additionally, clinical decision-making occurred during this session, contributing a total of 35 minutes of evaluation time, outside of the test administration.

Later that week, the patient returned for a follow-up visit to review the results. Before this visit, the provider thoroughly reviewed and interpreted the standardized test results, integrating clinical data and finalizing the report. The findings confirmed Mild Cognitive Impairment, suggesting early-onset dementia. A tailored treatment plan and medication management strategy were developed. During the follow-up, the patient was informed of the diagnosis, and an interactive feedback session was conducted to address questions and concerns.

Post-service work included completing the documentation and coordinating referrals to specialists for further care, ensuring a comprehensive approach to the patient's treatment and follow-up. A total of 60 minutes was spent on evaluation during this visit.

Overall, 95 minutes were spent on evaluation components, with 25 minutes dedicated to test administration. The services justify billing CPT codes 96132 and +96133, along with 96138 for the testing, conducted across multiple dates. Based on CPT and APA coding guidelines, neuropsychological testing and evaluation services should generally be submitted on a single claim, with each code reflecting the appropriate date of service.

However, it is important to follow payer-specific guidelines or EHR limitations that may affect submission practices. Be aware that reimbursement can vary based on individual payer policies, so verification with the payer is recommended.

Stay Informed on Neuropsychological Testing Coding for Accurate Reporting and Reimbursement

It's important to remember that specific requirements may vary by state and payer, making it essential to comply with all relevant laws and regulations regarding healthcare delivery. Understanding the nuances of CPT coding for neuropsychological and psychological testing is crucial for accurate reporting and reimbursement. By following outlined guidelines, adhering to payer requirements, and utilizing the appropriate codes, healthcare providers can ensure transparent documentation of services provided, thereby reducing the likelihood of denials.

Moreover, staying informed about updates in coding practices not only upholds compliance but also maximizes reimbursement opportunities, ultimately facilitating optimal patient care. Investing time in understanding these complexities can lead to more efficient billing processes and improved financial outcomes for your practice.

References

• https://www.who.int/news-room/fact-sheets/detail/mental-disorders 
• https://doi.org/10.1001%2Fjama.2013.13805 
• https://doi.org/10.1086%2F697566 
• https://doi.org/10.1093/sw/55.2.147 
• CMS. (2024). Medicare Benefit Policy Manual. Chapter 15 – Covered Medical and Other Health Services (Rev. 12532). Medicare Benefit Policy Manual (cms.gov)
• APA. (2019). 2019 Psychological and Neuropsychological Testing: Billing and Coding Guide. https://www.apaservices.org/practice/reimbursement/health-codes/testing/billing-coding.pdf