Clinical UM Guideline
|Guideline #:||CG-BEH-07||Current Effective Date:||10/06/2015|
|Status:||Revised||Last Review Date:||08/06/2015|
This document addresses psychological testing. The medical necessity criteria outlined in this document for psychological testing includes severity of illness which includes descriptions of the member's condition and circumstances.
Note: Please see the following related documents for additional information:
Severity of Illness (SI)
Psychological testing is considered medically necessary when the member has all of the following:
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. 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||[For dates of service on or after 10/01/2015]|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
Psychological testing is a comprehensive battery of tests and clinical interview 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. Responsibility for psychological testing services should rest with a qualified mental health provider who is licensed in their state of practice to do psychological testing. Screening 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 or other types of conditions where assessment contributes to the care of the member. 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) and duration of testing is also influenced by other cultural, linguistic and specific member needs. 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), however, in certain conditions more time may be needed when evaluating more complex cases. In addition to other clinical purposes, psychological assessment can be an integral aspect of pre-surgical assessments for procedures such as bariatric surgery, spinal stimulator implantation, or others. Psychological testing can also be performed to facilitate medical treatments such as chronic pain or diabetes management. Testing may be part of a comprehensive evaluation strategy or focused on a particular question. Focused testing, perhaps especially when part of an extensive clinical protocol, will tend to be brief, in the range of 3 hours.
National normative data includes scoring which results in standardized or scaled scores and the provider's assessments, recommendations and reports are based on techniques sufficient to provide substantiation for findings. An individualized test battery is employed and tailored to the specific referral question and individual member needs. Brief screening instruments and standardized questionnaires, which are 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. This is not to exclude the use of certain screening instruments when included as a part of a more comprehensive psychological assessment battery.
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:
|Revised||08/06/2015||Medical Policy & Technology Assessment Committee (MPTAC) review.|
|Revised||07/31/2015||Behavioral Health Subcommittee review. Added additional medically necessary statement from the Intensity of Service into the Severity section. Moved Intensity of Service into the Discussion/General information section. Updated Description, Discussion/General Information, and References.|
|Revised||01/30/2015||Behavioral Health Subcommittee review. Clarification to Medically Necessary Statement. Updated Discussion/General Information, References, and Index.|
|Reviewed||08/08/2014||Behavioral Health Subcommittee review. Updated Description, Discussion/General Information and References.|
|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.|