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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 08/21/2003 Title: Neuropsychological Testing
Revision Date: 01/01/2019 Document: BI005:00
CPT Code(s): 96116, 96118, 96120, 96121, 96125, 96132, 93133, 96136, 96137, 96138, 96139, 96146
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    All neuropsychological testing requires preauthorization. This includes performance of standardized cognitive performance testing such as the Ross Information Processing Assessment.

2)    Neuropsychological testing is used to aid in the assessment of cognitive impairment due to medical conditions. Testing is generally done by specially trained psychologists.

3)    Neuropsychological testing is generally covered by QualChoice when rendered for the diagnosis or evaluation of stroke or head injury with neurologic deficit.

4)    Neuropsychological testing may be covered for assessment of neurocognitive abilities related to other medical diagnoses, when the results of the testing will directly influence management of the patient’s condition. 

5)    The number of hours or units requested for testing should not exceed the reasonable time necessary to address the clinical questions with the identified measures. Usual testing time is four (4) to six (6) hours to perform (including administration, scoring, and interpretation.) For more than 6 hours of testing, medical necessity for the extended testing should be documented. Extended testing for more than 8 hours is not covered.

6)    Computerized neuropsychological testing that does not require professional interpretation and report is not covered.

7)    Use of telemedicine services for providing neuropsychological testing is not covered.


Medical Statement

1)    Neuropsychological testing (NPT) is considered medically necessary for cognitive evaluation when:

a)    There is a significant cognitive deficit, mental status abnormality, behavioral change, or memory loss that requires quantification or differentiation of cause, AND

b)    The suspected or known cause is one of the following:

i)     Multiple sclerosis (G35)

ii)    Dementia or other cognitive impairment as initial evaluation when diagnosis or severity is unclear (F01.50 – F03.91, G30.0 – G31.1)

iii)   HIV, Lyme disease, herpes encephalitis, or other infection associated cognitive disorders when there is a need for evaluation of significant cognitive deterioration (A69.20 – A69.29, B00.4, B20)

iv)   Primary progressive aphasia (G31.01)

v)    Cerebrovascular disease (I60.00 – I69.998)

vi)   Huntington disease (G10)

vii) Traumatic or anoxic brain injury (S06.0X0A – S06.9X9S)

viii)  Parkinson disease (G31.83)

ix)   Hydrocephalus (G91.0 – G91.9)

x)    Postsurgical change assessment in epilepsy

xi)   Cerebral dysfunction from known toxic exposure (T51 – T65 w/G92)

xii)   Cerebral mass (G93.9)

xiii)  Toxic effects of specific cancer treatment, AND

c)    There is an absence of active substance use, withdrawal, or recovery from recent chronic use

2)    NPT is medically necessary to aid in the diagnosis or exclusion of an organic or behavioral health disorder when ALL of the following are met:

a)    Detailed medical, neurologic, mental status, and psychiatric exams have been done as indicated

b)    Detailed medical diagnostic testing has been done as indicated

c)    Known potential causes have been adequately treated

d)    Significant findings, behaviors, or deficits persist without identified cause

e)    Proposed testing can answer a question that psychiatric evaluation, observation in therapy, or other assessment cannot.

3)    NPT is not considered medically necessary for diagnosis, evaluation, or treatment of attention deficit disorders, as there is no evidence in the medical literature to support its use in this setting.

4)    NPT is a diagnostic test and is not considered medically necessary for ongoing or recurrent monitoring of progression of cognitive impairment secondary to neurological or degenerative disorders.

Codes Used:

ACTIVE CODES

 

96116

Neurobehavioral status exam (clinical assessment of thinking, reasoning & judgment), by physician or other qualified health care professional, both face-to-face time w/the patient & time interpreting test results & preparing the report; first hour (code revised 1/1/19)

+

96121

     ea addtl hr (new code 1/1/19)

 

96125

Standardized cognitive performance testing per hr of a qualified health care professional`s time, both face-to-face time administering tests to the patient & time interpreting these test results & preparing the report

 

96132

Neuropsychological testing evaluation services by physician or other qualified health care professional, incl integration of patient data, interpretation of standardized integration of patient data, interpretation of standardized test results & clinical data, clinical decision making, treatment planning & report, & interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour (new code 1/1/19)

+

96133

     ea addtl hr (new code 1/1/19)

 

96136

Psychological or neuropsychological test administration & scoring by physician or other qualified health care professional, two or more tests, any method; first 30 mn (new code 1/1/19)

+

96137

     ea addtl 30 mn (new code 1/1/19)

 

96138

Psychological or neuropsychological test administration & scoring by technician, two or more tests, any method; first 30 mn (new code 1/1/19)

+

96139

     ea addtl 30 mn (new code 1/1/19)

 

96146

Psychological or neuropsychological test administration, w/single automated, standardized instrument via electronic platform, w/automated result only (new code 1/1/19)

DELETED CODES

 

96118

Neuropsychological testing, per hr of the psychologist`s or physician`s time, both face-to-face time administering tests to the patient & time interpreting these test results & preparing the report (code deleted 1/1/19)

 

96119

Neuropsychological testing, w/qualified health care professional interpretation & report, administered by technician, per hr of technician time, face-to-face (code deleted 1/1/19)

 

96120

Neuropsychological testing, administered by a computer, w/qualified health care professional interpretation & report (code deleted 1/1/19)


Background

1)    The discipline of neuropsychology is a subspecialty of psychology involving the use of extensive testing designed to identify and pinpoint various cognitive deficits. It specifically provides information relevant to the determination of the presence of neurological damage or dysfunction and associated functional deficits. This discipline has a narrow scope of established effectiveness within the peer-reviewed medical literature. After a brain injury or a stroke, an evaluation by a neuropsychologist may be very helpful in directing rehabilitative efforts, and in determining the prognosis for recovery.

2)    Neuropsychological tests and measures used for clinical purposes must meet standards for psychometric adequacy.  The American Academy of Clinical Neuropsychology requires the following:

a)    Acceptable levels of reliability

b)    Demonstrated validity in relation to other tests and/or to brain status, including evidence that the test or measure assesses the process, ability, or trait it purports to assess

c)    Normative standards that allow the clinician to evaluate the patient’s scores in relation to relevant patient characteristics, such as age, gender, and socio-demographic or cultural/linguistic background

3)    Repeat sessions of neuropsychological testing are generally not medically necessary, and will only be authorized in unusual circumstances.

4)    Advocates of neuropsychological testing urge its use for such problems as dementia and multiple sclerosis. However, the literature generally supports the position that such an evaluation, while it might be an interesting research tool, has no effect on directing therapy and does not change the prognosis or outcome of the individual patient. More precise documentation of a diagnosis when treatment decisions and outcomes are not dependent upon that documentation is not considered medically necessary. QualChoice does not cover this kind of testing.

5)    Part of the definition of “medically necessary and appropriate” is that the service will affect the decision regarding treatment or be effective in the treatment of the patient`s condition to improve outcomes. It may be true that neuropsychological testing can make the diagnosis of dementia or multiple sclerosis - but these diagnoses can be made accurately by other, much less expensive, means - and the testing is almost always added on to those other means rather than substituting for them.

6)  Neuropsychological testing is used in persons with documented changes of incognitive function to differentiate neurologic diseases (i.e.,, one of the types of dementia) or injuries (e.g., traumatic brain injury, stroke) from depressive disorders or other psychiatric conditions (e.g., psychosis, schizophrenia) when the diagnosis is uncertain after complete neurological examination, mental status examination, and other neurodiagnostic studies (e.g., CT scanning, MR imaging). The clinician presented with complaints of memory impairment or slowness in thinking in a patient who is depressed or paranoid may be unsure of the possible contribution of neurological changes to the clinical picture. Neuropsychological testing may be helpful when the findings of the neurological examination and ancillary procedures are either negative or equivocal.

7)    Computerized Neuropsychological Testing:

a)    Computerized neuropsychological testing is also referred to as automated or computer-based testing. This type of testing has been developed over the last 20 years (Schatz and Browndyke, 2002). There are features in computer-based testing that are absent in the traditional form of neuropsychological testing, including: timing of response latencies, automated analysis of response patterns, transfer of results to a database for further analysis or the ease with which normative data can be collated or compared to existing databases (Schatz and Browndyke, 2002). Limitations to computer-based testing include: unfamiliarity with the equipment by the patient and the potential for inaccurate timing procedures. Some of the tests are a translation of existing standardized tests into a computerized administration (e.g., Wisconsin Card Sorting Test™) while others are the development of new computer tests and batteries of tests (Wild, et al., 2008).

b)    Many of the tests associates with computerized testing were developed to evaluate for mild cognitive impairment or for sports-related concussion. Some of the tests have been adapted for testing in the pediatric populations, in particular for cases of attention-deficit/hyperactivity disorder (ADHD) (Luciana, 2003). These tests are also used in the research setting.

c)    Many of the computerized tests do not require a professional to interpret and complete a report. The computer program provides a report. The test may not involve a visit or evaluation of a neuropsychologist and may be administered by a non-skilled or unlicensed individual.

d)    Computerized testing offers advantage in certain circumstances, such as evaluating athletes for concussion, or in educational settings.  For clinical purposes these tests are not superior to simple bedside clinical testing.

8)    According to Hayes, overall, positive predictive power (PPP), or the percentage of patients with impaired scores being diagnosed with ADHD by standard criteria, was moderate too good for neuropsychological tests measuring attention, vigilance, response inhibition, and/or planning when ADHD patients were compared with normal controls. However, PPP was limited when ADHD patients were compared with controls with attention or related problems, suggesting that the tests` ability to identify ADHD patients among patients referred for attention problems is limited. In addition, negative predictive power (NPP), or the percentage of patients with normal scores not receiving an ADHD diagnosis by standard criteria, was low to moderate for most tests, suggesting that neuropsychological test scores should not be used to rule out ADHD. Thus, the utility of these tests for diagnosing ADHD in clinical practice appears to be low (Hayes, Neuropsychological Testing for Attention-Deficit Hyperactivity Disorder (ADHD), 2008).


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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