As demand for cognitive and psychological assessments continues to rise—especially among aging populations facing increased neurocognitive and mental health challenges—providers are under growing pressure to deliver high-quality care efficiently.
The U.S. is approaching a substantial paradigm shift in healthcare delivery, with adults aged 65 and older projected to exceed 20% of the population by 2040, a trend that will require systemic adaptation and place additional strain on an already stretched healthcare workforce. At the same time, delays and bottlenecks persist when outdated, manual workflows are used for testing, significantly slowing care delivery and limiting access.
CPT code 96138 represents more than just a reimbursement mechanism, it represents a more efficient, scalable approach to neuropsychological or cognitive testing. When paired with trained technicians and digital platforms, 96138 can standardize and streamline assessments across modalities, including computer, tablet, and traditional formats. By shifting to this model, practices can maintain clinical excellence while reducing operational friction.
This article aims to educate providers on how to implement CPT 96138 in real-world settings, clarify documentation and compliance essentials, and inspire a modernized vision for cognitive assessments that balances clinical effectiveness with efficiency and scale.
What Is CPT Code 96138?
This code is used for the administration and scoring of two or more psychological or neuropsychological tests by a technician under the general supervision of a qualified health care provider. This allows practices to delegate test administration while the licensed psychologist or neuropsychologist focuses on higher-level clinical interpretation and care planning.
Code 96138 is typically reported in 30-minute increments and is distinct from 96136, which is used for the administration of a single test.
Who Can Use 96138?
CPT 96138 may be used by a variety of healthcare professionals within the appropriate scope of their license and under applicable supervision requirements (CMS, 2025). Medical professionals who may use this code include:
- Licensed Psychologists
- Neuropsychologists
- Neurologists
- Physicians (MD, DO)
- Behavioral Health Providers
- Qualified Healthcare Professionals (QHPs)
In all cases, proper supervision of the technician and adherence to documentation requirements is essential for compliant use of 96138.
Who Qualifies as a Technician?
A technician administering psychological or neuropsychological testing under CPT 96138 does not need to hold a clinical license. However, they must be specifically trained in the standardized administration and scoring of validated cognitive assessments and must perform these tasks under the appropriate level of supervision—typically general supervision, unless otherwise required.
Eligible technician roles may include:
- Medical Assistants (MAs)
- Registered Nurses (RNs)
- Psychometrists
- Behavioral Health Aides
- Other trained clinical or administrative staff
For practices leveraging computerized or digital testing platforms, the technician role can often be filled by non-clinical personnel—such as administrative staff—once they receive focused training on test delivery protocols, proper patient instructions, and handling of technical issues. The key is ensuring consistency, accuracy, and adherence to standardized procedures.
Proper technician training is essential to ensure valid results, support compliance, and protect the integrity of the assessment process.
When Is 96138 Used?
CPT 96138 is frequently billed as part of a broader neurocognitive or psychological testing battery, commonly used to evaluate conditions such as ADHD, cognitive decline, memory impairment, mood disorders, and post-concussion symptoms—among many others. This can include evaluations for learning disabilities, traumatic brain injuries, behavioral disturbances, and diagnostic clarification in complex cases.
By delegating the administration of standardized assessments to trained technicians, providers can ensure that evaluations remain comprehensive, efficient, and patient-centered, without overwhelming their clinical schedules.
Why CPT 96138 Matters for Clinical Efficiency
Scalability
Delegating test administration enables providers to scale services without increasing workload. Instead of blocking off long appointment slots to administer tests manually, clinicians can rely on trained technicians to handle the bulk of the cognitive battery.
Enhanced Workflow
Practices that use technician-administered testing report reduced bottlenecks and improved patient throughput. Providers spend more time interpreting results and discussing care plans—where their expertise is most impactful—rather than managing the logistics of test delivery.
Cost-Effectiveness
Maximizing staff roles improves productivity and reimbursement. By leveraging technician administered testing under 96138, practices can tap into reimbursable technician time, while freeing up provider schedules to accommodate more evaluations, follow-ups, or high-level care tasks.
Technician Training Is Key
Efficiency doesn’t come at the cost of quality. Proper technician training ensures standardization, accuracy, and patient trust. Many practices implement internal checklists, periodic retraining, and digital tools that support technician workflows and compliance tracking.
Coding & Compliance Requirements
Supervision Requirements
CPT 96138 requires general supervision, meaning the supervising provider does not need to be physically present during testing but must be available for consultation. This differs from codes requiring direct supervision, where the provider must be onsite during the service. Always confirm supervision requirements based on state scope-of-practice laws and payer guidelines.
Proper Code Selection
Accurate coding for psychological and neuropsychological testing depends on two key factors: who performs the service and how much time is spent.
Test Administration by Physician or QHP
- 96136 – Administration and scoring of two or more tests, via any method, by a physician or QHP, reported in 30-minute increments.
- 96137 – Add-on code for each additional 30-minute increment of provider-administered testing.
Test Administration by Technician
- 96138 – Administration and scoring of two or more tests, via any method, by a trained technician, reported in 30-minute increments under general supervision.
- 96139 – Add-on code for each additional 30-minute increment of technician-administered testing.
Time Requirements and Minimum Thresholds
Codes 96136 and 96138 are reported in 30-minute units, however, per CMS and CPT guidance, you may bill one unit when a minimum of 16 minutes is met. This is known as the midpoint rule. Each additional unit requires at least 16 minutes over the initial 30 minutes of documented time.
- Track and document actual start and stop times or calculated durations.
- Time must reflect face-to-face technician or provider time spent actively administering the tests.
- Avoid rounding; ensure the recorded time aligns with units billed to reduce the risk of denials.
Evaluation Pairing
Test administration should be paired with the appropriate test evaluation code:
- 96130 / 96132 – These codes are used for professional time spent on activities such as record review, test selection, clinical decision-making, interpretation, treatment planning, and report generation.
These codes reflect the cognitive work and clinical judgment provided by a licensed professional, not the act of test administration itself.
Documentation Must-Haves
To ensure audit-readiness, documentation should include:
- Test names and descriptions
- Clinical rationale for test selection
- Duration of the test with total time
- Supervision type (general or direct)
- Any interruptions or test irregularities
Avoid Common Pitfalls
Accurate Time Tracking
Precise documentation of time spent is critical. Clearly record the total face-to-face time dedicated to test administration and scoring. For example: “Total time spent in test administration: 25 minutes.” Avoid vague or estimated times that can trigger audits or denials.
Prevent Unbundling Errors
Be mindful not to unnecessarily split services into separate codes. For instance, CPT 96127 (behavioral/emotional screening) is generally considered part of the overall test administration time captured by 96138 and should not be billed separately when performed concurrently. Instead, its time should be incorporated into the total time reported under 96138 to reflect comprehensive service delivery.
Consistent Documentation Practices
Use standardized templates and time logs to ensure consistency and support coding decisions during internal or external reviews.
Debunking Myths & Misconceptions Around 96138
Myth 1: Only Licensed Providers Can Administer Tests
While interpretation and clinical decision-making must be performed by a licensed provider or qualified healthcare professional (QHP), test administration itself can be delegated to trained technicians as long as it is performed under the appropriate level of supervision (typically general supervision for CPT 96138). This delegation model is fully compliant with CPT guidelines and widely accepted across payer policies.
Training technicians to administer standardized cognitive assessments—particularly through modern, computerized platforms—not only enhances provider efficiency but also broadens access to care. When implemented under proper supervision and with validated tools, this approach maintains the integrity and accuracy of the testing process.
Myth 2: Computerized Tests Aren’t Billable Under 96138
Contrary to common misconceptions, validated computerized assessments are billable under CPT 96138, as long as a trained technician is actively involved in administering the test. This code supports cognitive testing delivered via computer, tablet, or traditional paper-and-pencil methods.
However, fully self-administered or unsupervised assessments do not meet the criteria. The key compliance requirement is that a technician must be present to facilitate the testing session, ensuring two or more standardized tasks or batteries are administered in a structured, supervised environment. As always, reviewing payer-specific guidelines is essential to ensure proper billing and avoid denials.
Myth 3: Digital Tools Lack Validity
Not all digital cognitive tools are created equal. It’s essential to ensure any platform used is built on peer-reviewed, evidence-based assessments. Validated tools—like those provided by Creyos—undergo rigorous scientific review to ensure reliability, clinical relevance, and alignment with payer expectations.
When properly validated, these platforms not only meet documentation and reimbursement standards, but also enhance clinical accuracy, consistency, and workflow efficiency. Providers should always verify the scientific backing of any tool they implement.
Medical Necessity and Authorization
The fact is, services billed under 96138 must be clinically indicated. Many payers require prior authorization, especially for comprehensive neuropsychological batteries. Always verify specific payer policies and authorization needs to ensure compliance and smooth reimbursement.
Embracing Digital Tools for Technician-Led Assessments
Digital platforms have transformed how cognitive assessments are delivered:
- Automated scoring removes human error and accelerates result availability.
- Real-time time tracking helps ensure accurate documentation for compliance.
- Technician-guided workflows streamline administration and supervision.
- EHR integration allows assessments to flow directly into the patient record, minimizing manual entry.
- Remote testing (where permitted) in telehealth expands access while maintaining quality.
The key is to ensure all tools used are clinically and scientifically validated and supported by peer-reviewed evidence. The shift to digital doesn't compromise standards—it elevates them by improving consistency and removing administrative overhead.
Digital Transformation in Cognitive Testing
Platforms like Creyos offer structured, technician-friendly workflows that align closely with CPT 96138 requirements. Features like automatic scoring, built-in time documentation, and standardized test protocols help ensure practices remain compliant and audit-ready.
For example, a practice may use Creyos to administer a full cognitive battery through a trained technician. The platform tracks time, tests administered, and delivers ready-to-review results to the provider for interpretation under 96130 or 96132—streamlining both care and optimized reimbursement.
The Bigger Picture: Rethinking Cognitive Assessment for the Future
Modernizing cognitive assessment isn’t just about reducing manual workload, it’s a strategic transformation that improves care access, supports accurate diagnosis, and enhances financial sustainability.
By aligning workflows with CPT 96138 and adopting validated digital tools, practices can offer more patients timely assessments while ensuring that licensed providers focus on higher-value clinical tasks.
This shift is especially critical in primary care and behavioral health settings, where early detection of cognitive issues can drastically change treatment outcomes. Providers who think beyond compliance and toward smart, data-driven assessment workflows position themselves as leaders in modern patient care.
Unlocking the Future of Efficient Cognitive Assessments
CPT 96138 is more than just a code, it’s a gateway to streamlined, scalable, and compliant cognitive assessment workflows. By empowering trained technicians, leveraging modern digital tools, and maintaining compliant documentation standards, providers can confidently modernize their practices without compromising quality of care.
The future of value-based cognitive assessment is here. Now is the time to modernize, delegate, and scale with confidence.
References
- John A. Hartford Foundation. (2023). The growing demand for age-friendly care: Trends, challenges, and policy opportunities. https://www.johnahartford.org/images/uploads/resources/The_Growing_Demand_for_Age-Friendly_Care_Report_FINAL.pdf
- CMS. (2025). Medicare Benefit Policy Manual. Chapter 15 – Covered Medical and Other Health Services (Rev. 13051). Medicare Benefit Policy Manual (cms.gov)
- APA. (2024). 2024 Psychological and Neuropsychological Testing: Billing and Coding Guide. https://www.apaservices.org/practice/reimbursement/health-codes/testing/billing-coding.pdf
Written by Emily Montemayor, Medical Coding Support Manager at Creyos
With over a decade of experience in healthcare, Emily has finely honed skills in revenue integrity and auditing. Her current credentials include CCS, CMBCS, COC, CPC, CPMA. She's been a trainer and educator who's had the opportunity to support over 50 hospitals across the US and internationally. She's deeply committed to optimizing reimbursement and enhancing revenue integrity by ensuring compliance with regulatory standards and continuously improving coding and auditing practices.
Reviewed by Mike Battista, Director of Science & Research at Creyos
Mike Battista specializes in brain health, cognition, and neuropsychological testing. He received his PhD in personality and measurement psychology at Western University in 2010 and has been doing fun and useful stuff in the intersection between science and technology ever since.