Clinical UM Guideline
|Guideline #:||CG-BEH-07||Current Effective Date:||10/08/2013|
|Status:||New||Last Review Date:||08/08/2013|
The medical necessity criteria outlined in this guideline for psychological testing include two categories; Severity of Illness and Intensity of Service. Severity of Illness criteria includes descriptions of the Covered Individual's condition and circumstances. Intensity of Service criteria describes the services being provided.
This document addresses psychological testing.
Please see the following related document(s) for additional information:
Severity of Illness (SI)
Must have all of the following to qualify:
Intensity of Service (IS)
Note: Psychological testing for the purpose of assessing or screening Covered Individuals as part of a protocol for a surgical procedure (e.g., gastric by-pass surgery) or pain management program or to assess organic dysfunction related to a brain injury or brain damage is often covered as part of a comprehensive protocol or under the medical benefit. When this is not covered under the medical benefit, it should be reviewed by a physician/psychologist peer clinical reviewer.
Not Medically Necessary:
Psychological testing is considered not medically necessary when the above criteria are not met.
The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|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|
|ICD-10 Diagnosis||ICD-10-CM draft codes; effective 10/01/2014:|
Psychological testing is a comprehensive battery of tests to assess self-concept, cognitive skills, or personality traits. Psychological testing is to be performed by clinicians (for example, physicians, psychologists), appropriately trained to perform and interpret test results, when this type of testing evaluation falls within their scope of professional practice. There should be a reasonable expectation that the Covered Individual's illness, condition, or level of functioning will be stabilized, improved, or maintained through treatment known to be effective for the Covered Individual's illness.
It is noted that there is variation in the availability of services in different geographic and regional areas. If an indicated service is not available within a Covered Individual's community at the level of service indicated by the criteria, authorization may be given for those services at the next highest available level.
Psychological Testing: An objective and standard way of measuring an individual's mental or behavioral characteristics.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|New||08/08/2013||Medical Policy & Technology Assessment Committee (MPTAC) review.|
|New||07/26/2013||Behavioral Health Subcommittee review. Initial document development. Initial document development. Updated Clinical Indications Severity of Illness, #1 added the word "medical" to the evaluations. Updated References. The Behavioral Health Medical Necessity Criteria effective January 1, 2013 was split apart into specific subject matter clinical UM guidelines.|