What is CPT code 96138?
The 96138 Current Procedural Terminology (CPT) code is used to report psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; first 30 minutes. This serves as a base code for neuropsychological testing services when qualified technicians administer comprehensive evaluation services under professional supervision.
Neuropsychological test administration covers the systematic delivery of standardized psychological and neuropsychological testing services designed to assess cognitive function, mental health status, and behavioral patterns.
The CPT 96138 specifically covers psychological testing evaluation services performed by qualified technicians under the supervision of a licensed healthcare professional, distinguishing it from physician-led test administration and scoring.
Documentation requirements
Proper coding for CPT code 96138 requires comprehensive documentation supporting medical necessity and services provided. The clinical record must clearly establish the qualified healthcare professional's supervision of technician-administered testing and justify the initial 30-minute evaluation period covering two or more tests.
Documentation should specify the psychological and neuropsychological testing instruments administered, the time spent on each testing component, and the clinical rationale for the comprehensive evaluation. The practitioner providing oversight must document their involvement in test selection, result interpretation, and integration of clinical data into the overall assessment.
Time-based requirements
As a time-based code, CPT 96138 requires precise documentation of the first 30 minutes spent in test administration and scoring. The billing guidelines specify that this base code covers the initial period of face-to-face testing time when administering two or more neuropsychological tests.
Healthcare providers must document the start and stop times for testing sessions conducted on the same day, ensuring that the total time claimed aligns with the services performed. Interactive feedback sessions and automated result processing time are generally not included in the billable time for this code.
Supervision and qualification standards
Neuropsychological testing evaluation services require the supervision of a qualified healthcare professional. Documentation must reflect the supervising practitioner's involvement in treatment planning and clinical decision-making based on standardized test results obtained through technician administration.
Billing guidelines
CPT code 96138 functions as a base code for technician-administered neuropsychological testing services and can be billed independently when appropriate documentation supports the first 30 minutes of testing involving two or more tests.
Accurate billing requires proper documentation of the testing time and supervision requirements for comprehensive psychological testing sessions. Medicaid services and other payers may have specific requirements regarding the maximum number of add-on units billable per evaluation episode.
The billing guidelines specify that healthcare providers should report CPT code 96138 for the initial 30-minute period of technician-administered testing. Additional time beyond this base period would require appropriate add-on codes to capture extended evaluation services. Medicaid services and other payers may have specific requirements regarding the documentation and medical necessity for these testing services.
Other relevant codes
The following CPT codes commonly relate to neuropsychological testing evaluation services and may be used in conjunction with or as alternatives to CPT 96138:
- 96136 - Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method, first 30 minutes
- 96139 - Psychological or neuropsychological test administration by technician (each additional 30 minutes)
- 96116 - Neurobehavioral status exam
- 96125 - Standardized cognitive performance testing
- 90791 - Psychiatric diagnostic evaluation
- 90834 - Psychotherapy with patient (45 minutes)
Frequently asked questions
The average Medicare reimbursement rate for CPT code 96138, which covers the first 30 minutes of psychological or neuropsychological test administration and scoring by a technician, is $33.83.
CPT codes 96136 (test administration by a qualified healthcare professional) and 96138 (test administration by a technician) should not be billed together for the same time period or same test, as each code is specific to who performs the service; however, both codes can be billed for the same patient if the time for each service is counted separately and properly documented, with appropriate modifiers applied to avoid claim denials.
CMS requires the use of the -59 modifier on CPT codes 96138 and 96132 when billed with other services, such as evaluation and management (E/M) codes, to indicate that these procedures are distinct and separately identifiable from other services provided on the same day.
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