Q&A: CPT coding and reporting for psychological testing evaluation provided over multiple days

Q: Suppose a patient comes in for a psychological testing evaluation including the assessment of their scores from the Minnesota Multiphasic Personality Inventory and Rorschach tests. The provider interprets the test results and patient data, prepares a report, and begins treatment planning. If the interactive feedback session is held several days later, how would this be reported using CPT codes?

A: A physician coder would report CPT code 96130 (psychological testing evaluation services by physician or other qualified healthcare professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family members or caregivers, when performed; first hour).

The coder may also report add-on code 96131 (…; each additional hour) for each additional hour the provider spends providing psychological testing evaluation.

CPT code 96130 is all-encompassing — it includes the provider’s time spent interpreting test results and patient data, preparing a clinical report, treatment planning, and clinical decision-making. The provider may also review raw and standardized scores with any additional test data acquired from computer or technician testing. Evaluation services also include interactive feedback to the patient, family members, or caregivers. There’s nothing in the code descriptor for 96130 that says these services must be performed on the same day.

Under no circumstances would it be appropriate to submit add-on code 96131 on its own. You need to report the primary code and the add-on code together.

Since these are time-based codes, the provider should carefully report the time he or she spends providing these services, especially if services are performed over the course of multiple days. The provider may need to put the claim on hold until all the evaluation services are completed.

Suppose for example a provider sees a patient on July 25 and doesn’t complete all the elements of the psychological test evaluation until August 2— a week later. In this case, the provider should carefully document his or her time and submit the claim with 99130 on the later date, after all the evaluation components have been completed.

Editor’s note: This question was answered by Amber Condren, BS, B ED, CPC, CHA, CEMC, CMDP, senior managing consultant and director of coding at Soerries Coding and Billing Institute in Grain Valley, Missouri during the DecisionHealth webinar, “Psychological and Neuropsychological Testing Update for 2019.”