CPT Code 96136: Psychological or Neuropsychological Test Administration (First 30 Minutes)

What is test administration by provider?

CPT 96136 is one of the primary CPT codes for psychological testing. It represents the administration and scoring of psychological and neuropsychological testing by a qualified healthcare professional, billed in 30-minute increments. This 96136 CPT code applies to the in-person administration of two or more tests, such as assessments of memory, attention, executive function, and IQ.

These psychological testing evaluation services are commonly used in diagnosing cognitive conditions like traumatic brain injury (TBI), ADHD, dementia, and other mental health disorders. When conducted by a licensed professional rather than via automation, the code is relevant for psychological testing and neuropsychological test administration.

Test administration involves interpreting clinical data, selecting appropriate tests, and integrating standardized test results into a broader diagnostic framework. These results support treatment planning, clinical decision-making, and improved overall mental health care delivery.

In contrast to a single automated test administration using a single automated instrument, CPT 96136 requires the professional’s direct involvement in real-time psychological testing and evaluation. While computerized test administration and electronic platform tools may support testing, the value of 96136 lies in the interpretation and adaptation by a human evaluator.

This code is also critical for neuropsychological evaluation services and aligns with codes for psychological testing when billing for comprehensive psychological testing sessions. It is often combined with other key CPT codes to capture the full scope of psychological testing services.

Testing evaluation services must document medical necessity, describe the specific tests performed, and reference any clinical interview or examinations performed. Interactive feedback and patient data integration are essential to ensure accurate diagnosis and effective care.

When reporting 96136, accurate coding is vital for revenue cycle management, especially when working with payers such as Medicare. Understanding the nuances of this code and related CPT codes for psychological and neuropsychological testing ensures providers meet documentation standards and support ethical, effective testing in behavioral and mental health care.

Documentation requirements

Accurate documentation is essential for psychological and neuropsychological testing to ensure compliance with billing standards and support reimbursement through the correct billing codes. As new codes and newly created codes continue to evolve in the healthcare field, healthcare organizations must stay updated on documentation practices to streamline the billing process and justify medical necessity.

Each record should include the following:

• Reason for testing: Clearly document the diagnosis, referral concern, or clinical rationale for initiating testing. This helps determine the appropriate codes to use for psychological or neurobehavioral status exams.
• Tests administered and scoring method: List all tests used—whether electronic tests or paper-based—and detail the test administration and scoring approach. Include how results were derived and if any standardized tools were used.
• Time spent face-to-face with patient: Specify the duration of direct interaction, especially when billing for time-based codes like 96136. If applicable, include time for each additional hour beyond the initial service.
• Observations during testing: Note behavioral responses, attention level, motivation, and any concerns observed during administration, which may influence scoring and interpretation.
• Integration into overall assessment: Demonstrate how findings contribute to diagnostic clarity and guide treatment or care planning. This supports the clinical value of the testing performed.

Billing guidelines

CPT code 96136 is billed in 30-minute increments for psychological testing evaluation services, including test administration and scoring by a qualified healthcare professional. For each additional hour or 30-minute segment beyond the initial time, use 96137. These codes may be billed alone or with evaluation and interpretation codes such as 96130 and 96132. However, they should not be billed together with technician-administered test codes (96138–96139) for the same time period to avoid duplicate billing.

Ensuring time thresholds are met and clearly documented in the patient record to support appropriate reimbursement is critical. Using these billing codes helps healthcare providers maintain compliance and optimize revenue cycle management.