There are many services billed to insurance companies where the time spent with the patient can impact reimbursement. These services can be found throughout various sections of both CPT and HCPCS codes including, but are not limited to evaluation and management, physical therapy, home health, nursing visits, speech therapy, and behavioral health. When time is a component of the code, the medical records should clearly indicate the amount of time spent performing the service.
Let's explore the psychological testing codes which include the time component. According to the American Psychological Association (APA), psychological testing "involves the use of formal tests such as questionnaires or checklists. These are often described as 'norm-referenced' tests. That simply means the tests have been standardized so that test-takers are evaluated in a similar way, no matter where they live or who administers the test. A norm-referenced test of a child's reading abilities, for example, may rank that child's ability compared to other children of similar age or grade level. Norm-referenced tests have been developed and evaluated by researchers and proven to be effective for measuring a particular trait or disorder."
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There are several procedure codes used to bill for various types of psychological testing depending on the nature of the testing and the qualifications of the rendering provider. This week's article will focus on the following procedure codes:
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96101
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Psychological testing, interpretation and reporting per hour by a psychologist (per hour)
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96102
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Psychological testing per hour by a technician (per hour)
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96103
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Psychological testing by a computer, including time for the psychologist's interpretation and reporting (per hour)
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What types of tests are performed?
The types of psychological tests may vary. However, one well-known example is the Rorschach Test, better known as the inkblot test. The Rorschach Test was originally created in 1921 byHermann Rorschach when 10 inkblots were printed on cards and published in Psychodiagnostik. While this test has fallen to controversy over the years, it is still commonly used to gain "better insights into the underlying motivations of the person's current issues andbehaviors."[2]
How is it billed?
Psychologists or Physicians may bill CPT 96101 per hour of for face-to-face time administering the tests or for the time spent interpreting the tests and preparing the report. CPT 96101 is not to be billed for the interpretation and report of 96102 or 96103.
CPT guidelines do not specify how many hours in a day these tests should be billed. However, many plans have developed their own policies with unit limitations. For example, UnitedHealthcare lists a maximum number of units of 8 or 8 hours for both 96101 and 96102 as well as a maximum unit of 1 or 1 hour for 96103.[3] Other payers such as Blue Cross Blue Shield of Rhode Island show a maximum unit threshold of 6 per calendar year. [4]
What to look for?
Here are some areas you can data mine for potential FWA:
- Look for providers billing excessive units per day as well as per calendar year for either 96101, 96102, 96103.
- Look for unbundling 96101 with 96102 or 96103.
- Look for providers who are not licensed psychologists or physicians billing for 96101
- Look for split claims where providers are attempting to bypass any unit limitations by submitting under different claims.
Using a data mining tool such as PostShield, can help identify these aberrant billing patterns and more.
Does your FWA system integrate external data, social media and other information from the web? If not, contact Healthcare Fraud Shield for more information.
If you have any questions, you may email our Subject Matter Experts atSIU@hcfraudshield.com.