Medical Policy

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)

Limits
Intentially left empty
Reference
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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.