Clinical UM Guideline


Subject:Psychological Testing
Guideline #:  CG-BEH-07Current Effective Date:  04/07/2015
Status:RevisedLast Review Date:  02/05/2015

Description

This document addresses psychological testing. The medical necessity criteria outlined in this document for psychological testing include two categories; Severity of Illness and Intensity of Service. Severity of Illness criteria includes descriptions of the member's condition and circumstances. Intensity of Service criteria describes the services being provided.

Note: Please see the following related documents for additional information:

Clinical Indications

Medically Necessary:

Severity of Illness (SI)
Must have all of the following to qualify:

  1. Must be for the purpose of helping to establish the diagnosis of and to develop a treatment plan for a mental disorder, when this information is not adequately available from one or more comprehensive medical or behavioral health evaluations with the member and appropriate ancillary sources (for example, family members, health care providers, school records); AND
  2. It should not be for the primary purpose of assessing learning disorders, vocational testing or educational planning, unless allowed by local plan clinical guidelines. Custody evaluation, court referral for evaluation (unless medically necessary) and testing for research purposes, are not covered; AND
  3. There is evidence to suggest that the testing results will have a timely and direct impact on the member's treatment plan.

Intensity of Service (IS)

  1. The services must be provided by a mental health provider who is licensed in their state of practice to do psychological testing.
  2. The provider's assessments, recommendations and reports are based on techniques sufficient to provide appropriate substantiation for their findings. A select test battery is therefore employed and tailored to the specific referral question, rather than the use of a more standard, general battery.
  3. Standardized tests that are based upon published national normative data, with scoring resulting in standardized or scaled scores, may be approved.
  4. Brief rating scales, and standardized questionnaires administered by computer or those not requiring face-to-face administration are not considered to be psychological testing, but can be done as part of a professional visit.

Not Medically Necessary:

Psychological testing is considered not medically necessary when the above criteria are not met.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. 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.

CPT 
96101Psychological 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
96102Psychological 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
96103Psychological 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-9 Diagnosis[For dates of service prior to 10/01/2015]
 All diagnoses
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
 All diagnoses
  
Discussion/General Information

Psychological testing is a comprehensive battery of tests to assess self-concept, cognitive skills, or personality traits. Psychological testing is the responsibility of physicians and psychologists appropriately trained to perform and interpret test results, when this type of testing evaluation falls within their scope of professional practice. Testing can also be performed by other qualified health care professionals and/or through the use of a computer. There should be a reasonable expectation that the member's illness, condition, or level of functioning will be stabilized, improved, or maintained through treatment known to be effective for the member's illness. The duration of testing tends to vary based on the goal of the evaluation, the health of the person being examined and the age of the person being examined (Sweet, 2011). Testing for clinical reasons tends to be briefer than testing for educational and forensic purposes. A complete evaluation for clinical purposes, including any pre-testing examination, can usually be completed in 8 hours or less, sometimes in as few as 2 to 3 hours. Psychological testing can be an integral aspect of pre-surgical assessments for procedures such as gastric bypass surgery or placement of a spinal implant for the management of chronic pain. More generally, psychological testing can be performed as an aspect of chronic pain management. Testing may be part of a comprehensive evaluation strategy. Focused testing, perhaps especially when part of an extensive clinical protocol, will tend to be brief, in the range of 3 hours.

Definitions

Psychological testing: An objective and standard way of measuring an individual's mental or behavioral characteristics.

References

Peer Reviewed Publications:

  1. Austin H, Smith K, Ward WL. Psychological assessment of the adolescent bariatric surgery candidate. Surg Obes Relat Dis. 2013; 9(3):474-480.
  2. Stephens KA, Ward A. Patient selection for spinal cord stimulators: mental health perspective. Curr Pain Headache Rep. 2014; 18(3):398.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Child & Adolescent Psychiatry. Practice Parameters. Available at: https://www.aacap.org/aacap/Resources_
    for_Primary_Care/Practice_Parameters_and_Resource_Centers/Practice_Parameters.aspx. Accessed on December 30, 2014.
  2. American Psychiatric Association. Clinical Practice Guidelines. Available at: http://www.psych.org/practice/clinical-practice-guidelines. Accessed on December 30, 2014.
  3. American Society of Addiction Medicine Treatment. Available at: http://www.asam.org/research-treatment/treatment. Accessed on December 30, 2014.
  4. Centers for Medicaid & Medicare Services (CMS). First Coast Service Options, Inc. Local Coverage Determination for Psychological and Neuropsychological Testing (L33688). Revised 02/01/2014. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?list_type=ncd. Accessed on January 6, 2015.
  5. Centers for Medicaid & Medicare Services (CMS). Wisconsin Physicians Services. Local Coverage Determination for Psychological and Neuropsychological Testing (L31990). Revised 02/01/2014. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?list_type=ncd. Accessed on January 6, 2015.
  6. Mattson M. Manual of psychiatric quality assurance: American Psychiatric Association committee on quality assurance. 1st ed. Arlington: American Psychiatric Publishing. 1992.
  7. Sweet JJ, Meyer DG, Nelson NW, Moberg PJ. The TCN/AACN 2010 "salary survey": professional practices, beliefs, and incomes of U.S. neuropsychologists. Clin Neuropsych. 2011; 25(1):12-61.
Index

Neuropsychological Testing
Psychological Testing

History

Status

Date

Action

Revised02/05/2015Medical Policy & Technology Assessment Committee (MPTAC) review.
Revised01/30/2015Behavioral Health Subcommittee review. Clarification to Medically Necessary Statement. Updated Discussion/General Information, References, and Index.
Reviewed08/14/2014MPTAC review.
Reviewed08/08/2014Behavioral Health Subcommittee review. Updated Description, Discussion/General Information and References.
New08/08/2013MPTAC review.
New07/26/2013Behavioral 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.