Medical Billing Codes and the T.O.V.A.

Medical billing has not gotten easier in recent years, and some T.O.V.A. users have questions about how they can ensure third-party reimbursement for using the T.O.V.A. Billing practices vary widely from region to region in the U.S., and even across third party payers. While there is no substitute for a consultation with a competent coding expert, here are some guidelines that you might find useful.

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Introduction

Effective January 1st, 2006, CPT codes used for billing of psychological and neuropsychological tests were changed. Claims must now be filed using codes depending upon who performed the testing – the clinician, a technician, or if testing was solely computer-based. In some cases, testing time may be reported using one code and interpretation and report writing time may be reported using another.

The procedures to follow will depend upon the third party payer's individual preferences. Billing practices vary widely by region and by payer, and you may wish to consult your third party payers, or a billing specialist in your area for assistance on coding requirements in your area.

In general, we suggest that you report time as accurately as possible by tracking the amount of time spent for each component of a visit–the interview, test administration, interpretation, and report writing. Note that psychological testing codes normally round up or down at the 30 minute mark. Testing of less than 30 minutes duration may not be separately reimbursable, or may be "bundled" into other services provided during a visit. Testing that requires greater than 30 minutes is rounded to the next full unit (hour). The T.O.V.A. typically requires about 40-50 minutes for administration, interpretation to patients and/or caregivers, and documentation.

For Medical Providers (MD or DO)

For psychological and neuropsychological testing, medical providers utilize the same billing codes that are used by psychologists. In addition, physicians are able to utilize E/M codes. If you cannot work out reimbursement for the T.O.V.A. from a specific third party payer, you should be able to subsume T.O.V.A. administration and interpretation in an E/M code for an office visit. However, in general, you should be able to utilize one of the following CPT codes (the choice of which may be dictated by the terms of your contract with third-party payers):

96101 This code describes psychological testing, interpretation and reporting per hour by a physician or clinical psychologist. Billed as one unit per hour. Includes a brief face-to-face interview with the patient, test administration, interpretation, and report writing. This would be appropriate if, as a provider, you administer, interpret, and document the T.O.V.A. yourself.
96102 This code describes psychological testing per hour by a technician. At the present time, third party payers have different payment protocols for reporting the time spent by a technician versus a physician or psychologist in scoring, interpreting and writing a report. It is critical to know your payers expectations. For example, Medicare requires that the physician or psychologist report the time they spend interpreting and report writing under the same CPT code as the technician when a technician conducts testing.
96103 This code describes psychological testing by a computer, including time for the physician's or clinical psychologist's interpretation and reporting. Some third party payers may require use of this code for the T.O.V.A. however, according to the APA Testing Codes Toolkit document, Questions and Answers about Using the Computer Billing Code, "[t]he computer code is used only when the patient is taking a computer-based test unassisted" (American Psychological Association, 2006). Since the T.O.V.A. was normed with a professional or technician present with the individual in the testing room (instructing the examinee in use of the T.O.V.A. and occasionally redirecting them), the appropriateness of this code is questionable. For a T.O.V.A. administration to be valid, a clinician or technician must be present in the room during administration.
96111 This code is used to describe 'developmental testing; extended,' with interpretation and report. This code includes assessment of motor, language, social, adaptive, or cognitive functioning by standardized developmental instruments, which includes the T.O.V.A.
90801 Psychiatric diagnostic interview examination. You may find that you can also utilize this code as part of a patient visit that includes the T.O.V.A.. This procedure code is described as 'the elicitation of a complete history, establishment of tentative diagnosis, and an evaluation of the patient.' It must include a complete mental status exam. Note that this service may only be used once per patient at the onset of each new illness, suspected illness, or an exacerbation of an existing illness. Many payers require that a 90801 be performed in advance of any type of psychological or neuropsychological testing as it is that evaluation that determines the medical necessity for further investigation. An evaluation and management (E&M) service may be substituted for the initial interview procedure, including consultation codes (CPT 99241-99263), provided required elements of the E&M service billed are fulfilled. Consultation services require, in addition to the interview and examination, the provision of a written opinion and/or advice. Consultation codes do not include psychiatric treatment (Minnesota Psychiatric Society, 2007; see website at http://www.mnpsychsoc.org/MA.pdf). Remember – consultation codes and E/M codes may only be used by a physician.
90862 This code describes pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy. This code is not intended to be used for the actual administration of medication, nor is it intended to be used for observation of the patient taking an oral medication. CPT code 90862 is also not intended to refer to a brief evaluation of the patient and simple dosage adjustment of long-term medication. Medication management services of ten minutes or less should be reported using CPT code M0064. CPT code 90862 refers to the in-depth management of psychopharmacologic agents, which are potent medications with frequent serious side effects, and represents a very skilled aspect of patient care (Minnesota Psychiatric Society, 2007; see www.mnpsychsoc.org/MA.pdf). Utilization of the T.O.V.A. as part of a visit done to review medication effects may be coverable under this code.

For Clinical Psychologists

Many of the billing codes usable for testing by psychologists are comparable to those used by physicians.

96101 This code describes psychological testing, interpretation and reporting per hour by a physician or psychologist. Billed as one unit per hour. Includes a brief face-to-face Interview with the patient, test administration, interpretation, and report writing.
96102 This code describes psychological testing per hour by a technician. At the present time, third party payers have different payment protocols for reporting the time spent by the physician or psychologist in scoring, interpreting and writing a report. It is critical to know your payer expectations. Medicare requires that the physician or psychologist report the time they spend interpreting and report writing under the same CPT code as the technician when a technician does the testing.
96103 Psychological testing by a computer, including time for the physician's or clinical psychologist's interpretation and reporting. Some third party payers may require use of this code for the T.O.V.A. however, according to the APA Testing Codes Toolkit document Questions and Answers about Using the Computer Billing Code, "[t]he computer code is used only when the patient is taking a computer-based test unassisted." (American Psychological Association, 2006). Since the T.O.V.A. was normed with a professional or technician present with the individual in the testing room (instructing them in use of the T.O.V.A. and occasionally redirecting the examinee), the appropriateness of this code may be in question. In order to match the conditions under which the T.O.V.A. normative data was collected, a professional or technician must be present throughout the T.O.V.A. test.

Additional information on the use of CPT codes in psychological billing can be found at the American Psychological Association practice support website in the Testing Codes Toolkit at http://www.apapractice.org/apo/toolkit.html.

For Neuropsychologists

Use of neuropsychological testing codes may depend upon the diagnosis ultimately formulated. Note that the patient's diagnosis as well as the provider's credentials should direct the use of one set of codes versus the other. Neuropsychological tests are typically attached to a medical diagnosis.

96118 This code describes neuropsychological testing, interpretation and reporting per hour by a physician or a psychologist. Billed as one unit per hour. This code covers testing of I.Q., memory, attention, problem solving, processing speed, mental flexibility and other neuropsychological tests. This is the appropriate code if you personally administer, interpret, and write a report describing T.O.V.A. results.
96119 This code describes neuropsychological testing per hour by a technician. At the present time, third party payers have different payment protocols for reporting the time spent by the psychologists and technicians in scoring, interpreting and writing a report. It is critical to know your payer expectations. Medicare requires that time spent interpreting and report writing be under this code when a technician does the testing.
96120 Neuropsychological testing by a computer, including time for the physician's or clinical psychologist's interpretation and reporting. Some third party payers may require use of this code for the T.O.V.A. however, according to the APA Testing Codes Toolkit document Questions and Answers about Using the Computer Billing Code, "[t]he computer code is used only when the patient is taking a computer-based test unassisted." (American Psychological Association, 2006). Since the T.O.V.A. was normed with a professional or technician present with the individual in the testing room (instructing them in use of the T.O.V.A. and occasionally redirecting the examinee), the appropriateness of this code may be in question.

Again, please note that the patient's diagnosis as well as the provider's credentials should be taken into consideration when utilizing neuropsychological testing codes. These codes are typically associated with assessment when a medical diagnosis is present.

Some Additional Guidelines

In general, any time less than 30 minutes is not billable as a separate service. However, this may depend on the payer. Below is an excerpt from Medicare guidelines:

CPT codes 96101, 96102, 96105, 96110, 96111, 96116, 96118 or 96119, are reported as one unit per hour. If 30 minutes to one hour of time is spent performing the test, interpretation and report, one unit of time should be billed. If the psychological testing, interpretation and report requires less than 30 minutes, the definition of the CPT code has not been met and the testing may not be billed. CPT codes 96101 and 96118 are used to bill, in hourly units, the provider's time, both face-to-face with the patient and the time spent interpreting test results and preparing the report. The codes may not used to bill for the interpretation of tests administered by a technician or computer. When a provider performs some tests and a technician or computer performs other tests, documentation must demonstrate medical necessity for all tests. The provider time spent on the interpretation of the tests performed by the technician/computer may not be added to the units billed under CPT code 96101 or 96118. Medicare will not pay twice for the same test or the interpretation of tests.

CPT codes 96102 and 96119 include both the face-to-face technician time and the qualified health care provider's time for the interpretation and report. The provider who interprets the report must be available to furnish assistance and direction to the technician administering the test. Add the time the provider spends interpreting and reporting the test to the time technician spends administrating the tests.

CPT codes 96103 and 96120 describe tests administered by a computer and the interpretation and report performed by a qualified health care professional. Billed as one service regardless of the number of tests taken by the patient. The provider who interprets the report must be available during the time the patient is taking the test. The interpretation of the test is included in the codes and is not separately billable. These codes may not be billed for scoring of tests. When a provider and a technician administer different medically necessary tests, the interpretation must be allocated to the appropriate CPT code. Computerized tests are billed once and include the interpretation and report.

Other guidelines

Note that MD's can bill E/M codes. Neuropsychologists will need to either do all the work and bill under 96118 or bill both the psychologist's time and technician time all under 96119.

"When should 96101 or 96102 be used, instead of 96118 or 96119?"

96101, 96102 and 96103 are used when psychological tests are performed. 96118, 96119 and 96120 are used when neuropsychological testing is performed. In the event that there are tests that could be either, the patient's diagnosis as well as the provider's credentials should direct the use of one set of codes versus the other. In addition, neuropsychological tests and codes are typically attached to a medical diagnosis.

As always, please contact us if you have any questions on billing codes and the T.O.V.A.