Clinical Guide: Psychological and Neuropsychological Testing
This guide outlines the main categories of psychological and neuropsychological testing services. The evaluating clinician is responsible for selecting clinically appropriate tests, documenting medical necessity, recording actual work and time, and selecting codes that match the service and payer rules. Help Therapy handles claim submission and can review coding questions at billing@helptherapy.com.
Common service categories
90791 describes a psychiatric diagnostic evaluation when its requirements are met. Neurobehavioral status examinations use 96116 and, when appropriate, add-on 96121. Professional psychological test evaluation services use 96130 with add-on 96131; neuropsychological evaluation services use 96132 with add-on 96133. These evaluation services can include clinical integration, interpretation, decision-making, report preparation, and feedback under the applicable code description.
Test administration and scoring by a qualified professional may use 96136 and add-on 96137; technician administration uses 96138 and add-on 96139 when the service qualifies. Other codes, including 96127 for brief standardized assessments and 96146 for automated testing, have distinct requirements. Do not treat a questionnaire sent through SimplePractice as automatically billable under a particular testing code.
Record the date and duration of each distinct activity, tests used, who performed and scored them, interpretation, findings, and how the results informed care. Enter work on the date it actually occurred. If interview, administration, interpretation, report preparation, or feedback happens on different dates, ask billing how to report the services under the payer’s rules; do not shift dates merely to combine them on one appointment. Add-on codes must be paired with an eligible base service as the code and payer require.
Unit limits, code combinations, and coverage differ by payer and Medicare contractor. Do not use a fixed number of units or a generic testing-to-evaluation ratio as a universal maximum. Confirm medical necessity and current payer edits before billing unusually long or complex evaluations. CMS testing guidance: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=57481
For coding, documentation, or SimplePractice entry questions, contact billing@helptherapy.com before locking the encounter.