Dr. Jeremy Sharp (00:00)
Hey folks, welcome back to another episode of the Testing Psychologist. We are firmly in pillar two of the March sprint and pillar two is all about business stuff. And today’s business episode is all about coding, coding, coding. So there are plenty of deep dives out there on coding and we could talk about coding and insurance billing ad nauseum. Today though, I’m gonna go over some of the…
high-level concepts and make sure that you are billing correctly for the work that you’re doing and maybe even maximizing your billing a bit by using some of the more obscure codes that you may not be aware of.
So if you have ever looked at an EOB and wondered why one insurance company paid for the entire evaluation while another denied the entire evaluation, I think this episode is for you. Many clinicians are unfortunately leaving thousands, if not tens of thousands of dollars on the table just because of missed billing opportunities or rejections and denials simply because you aren’t coding correctly or maximizing billing.
We’re gonna do a little bit of a dive. I don’t know if I call it a deep dive, but a dive into the 12 specific CPT codes for testing. We’ll cover what I’ll call kind of the core stack that you use every day, and then we’ll look at some specialty codes like 96121 and 96116 that can significantly impact your bottom line for specific populations.
So before we jump to the episode, as per usual during the sprint, I am promoting my in-person event, Crafted Practice. This is the in-person business retreat for testing folks. I’ve done it every year for the past three years. This will be a year four. And it’s an all-inclusive business retreat where you come to Northern Colorado for four days. We do small group coaching. We have implementation time to actually work on things.
You get to connect with 20 folks who understand your life and your practice. And it’s just a really good time. ⁓ The relationships that have been built over the years have turned into what seemed like pretty lifelong, you know, long-term friendships and connections. So if that sounds interesting, go check out the testingpsychologist.com slash crafted practice and see if it is a good fit for you. I would love to see you there for now. Let’s dive into our discussion about insurance billing.
Dr. Jeremy Sharp (02:39)
All right, folks, we’re back. We’re talking about coding and billing. And I’m going to start with a discussion of what I would call the core stack of codes, which is 907.91, 96132, and 96133. Now, you might be saying already, what about 96130 and 96131? I will talk about those, of course, but give me a minute. OK, so let’s start with 907.91. This is where every evaluation should start.
This is your diagnostic interview, it’s your clinical intake. And one common mistake that people make is skipping over 907.91 and just rolling the intake into the other evaluation codes. Do not do that. 907.91 is one of the highest, if not the highest reimbursing code in your contract for most insurance panels. So you definitely don’t want to skip it. You will use that for up to the first
Dr. Jeremy Sharp (03:36)
60 minutes of history gathering with your client. The minimum threshold for a 907.91 is generally recognized as 16 minutes. So just be mindful of that. But I don’t know many of us who are doing shorter than 16 minute diagnostic interviews. So use that 907.91 to capture the first 60 minutes of your eval. Now let’s move to the professional work.
codes 96132 and 96133. So first off, these are 60 minute codes, 60 minute codes. That’s going to be important because not all of them are 60 minute codes. But 96132 and 133 are 60 minute codes. 96132 is the base unit. It covers the first hour of your professional work. So record review, integration of data, report writing, that kind of thing.
96133 is the add-on unit. This is for every additional hour of that same integration work. A question that comes up very often is, can I bill multiple units of 96132 if I perform the service on different days? And despite what you may have read or some of the literature that’s out there, yes, you can generally bill multiple units of 96132 on different days.
Every day that you perform that service, you’re gonna start with a 96132, and then if it goes past an hour, you’re gonna add on those units of 96133 to capture that additional time.
I want to note that these codes are going to cover the majority of your work on an evaluation. So these codes should cover literally anything that you do outside of the literal test administration and scoring. ⁓ Anything aside from test administration and scoring should be billed under 96132 and 96133. So some things that come to mind that people may miss.
Battery planning, record review, data integration, collateral interviews, conceptualization, thinking time, feedback, report writing, all of these things go under the codes of 96132 and 96133. So a lot of people I will see will make the mistake of billing the test administration codes for this higher level and theoretically higher reimbursement professional.
So I mentioned a bit ago, we are going to come back to 96130 and 96131. This is psychological testing and evaluation codes. So this is essentially the psych testing equivalent of 96132 and 96133, which are the neuropsych testing codes. All right. So what does that actually mean? This is still up in the air and debatable. It’s been hard to find a real concrete answer.
Dr. Jeremy Sharp (06:41)
Generally, 130 and 131 are used for psychological evaluations where we’re looking at personality and emotional functioning primarily, all right? Whereas 132 and 133 are used for neuropsych evals. You do not have to be a board-certified neuropsychologist to build these codes, at least at the moment. And this gets into the realm of cognition, memory, executive functioning, and the like. So a rule of thumb, you know,
If the primary referral is rule out depression slash personality disorder, and you’re really only administering personality measures or socio-emotional measures, questionnaires, that’s gonna generally be a 96130 and a 96131. But if the question is rule out ADHD or dementia or any medically complex eval, then you’re gonna move into the territory of 96132.
⁓ Using the wrong type of evaluation code can be a primary reason for claim denials. So you want to make sure that your primary diagnosis on the claim matches the code that you are using.
Okay, let’s move on to test administration and scoring. These are 96136 and 96137.
And like I said, this is the literal test administration and scoring and nothing else. Nothing else. OK? So this is the time that you spend setting up, administering, scoring, and cleaning up the testing materials. All right? Nothing else goes under this. It goes under these codes. Everything else should go under the professional work codes that we just talked about. Now, in a little twist, these codes, 136 and 137,
are 30 minute codes, whereas the previous codes were 60 minute codes, these are 30 minutes. So 96136 is the first 30 minutes of you sitting across from the client with a test kit. 96137 is every additional 30 minutes. So note these time differences again. This is where people get tripped up. The professional codes are hourly. These test administration codes are half hourly. So if you were to spend four hours testing,
You’re billing one unit of 96136 to capture that first half hour and then seven units of 96137 to capture the additional three and a half hours.
Dr. Jeremy Sharp (09:13)
So a question that comes up a lot is, why am I getting denied? How many units can I bill? That kind of thing. So this is going to vary depending on insurance panels. That’s the disclaimer here. But generally, many billers, and this matches my experience, will report that insurance companies have kind of a soft cap of six total hours of test administration. It’s kind of uncertain. This does not appear to be a universal policy.
But a lot of the commercial panels, especially the big ones, seem to have the soft cap of six total hours of test administration per day. So that’s 12 units. Something that is important to know is that ⁓ this is often a per day limit, not a per evaluation limit. So you could bill 12 units of test administration and scoring on one day. And then if you have some extra scoring to do, you could
bill another 96136 and additional units of 96137 on a different day.
Now, as far as the professional work codes, the soft cap seems to be eight units per day. It’s either, I’m gonna backtrack actually, it’s either four or eight units per day.
And remember, those are hourly units. So that’s either four or eight hours of professional work per day, 96132 and 96133. OK. So insurance companies tend to be a little more comfortable seeing, like I said, four to eight hours of those professional work code. If you were to build 12 units of professional work codes, ⁓ that would likely ⁓ trigger some attention, not the good kind.
All right. All right. So let’s talk about some specialty and more obscure codes and timing strategies for your billing. And this is where we get into a little bit more precision that can kind of maximize your work, I think, and eke out some extra legitimate payments for the work that you’re doing. OK. So let’s start with 96116 and 96121. These are meant to capture the neurobehavioral status exam.
So if you’re assessing a patient with a known or suspected brain injury, stroke or neurodegenerative disease, know, something like that, you could be looking at 96116, okay? This is kind of a specialized interview, mental status exam, but 96116 is the first hour, okay? And then 96121, don’t ask me why it’s 1-2-1 and not 96117.
But 96121 is each additional hour. So this is the add-on code for 96116. In many contracts, these codes can reimburse higher than some of the other professional work codes, or even a 90791, because they require specific neuropsych knowledge. A second set of codes that you could look at are 96112 and 96113. These are meant to account for developmental testing. So for the pediatric folks out there,
Dr. Jeremy Sharp (12:28)
If you’re doing a developmental screen for a kiddo, think for autism or early childhood delays and things like that, you could use 96112 for the first hour and 96113 as your add-on code. So these codes are specifically for observing and testing developmental milestones, and they’re often processed differently in the insurance system than standard eval codes.
Also wanted to do a little section just on timing and the number of units. So earlier, I gave all the time specifications for each unit, or each code, But just to recap, 907.91 is an untimed code. So you’ll bill one unit for any amount of time that you spend with the client, as long as it’s 16 to about 90 minutes.
But the other codes are time-based, which means you can maximize the time that you bill by billing exactly the least amount required. OK, what does that mean? That means that for 96132, 133, 130, 131, 136, 137, ⁓ you have to reach what I would call the half plus one minute threshold to bill for an additional unit. So for the 60-minute codes, you can bill an additional unit
as long as you spend at least 31 minutes performing that service. So you get that? So half plus one, half of 60 is 30 minutes plus one, 31 minutes. So if you spend 31 minutes performing that service, you can bill an additional unit of that code. For the 30 minute codes, you can bill an additional unit if you spend 16 minutes performing that service, okay? So in essence, you’re getting paid for the full hour or half hour, even though you only spent
of that time. This may not sound like much, but over the course of months or years, it definitely adds up. right? So again, just being mindful of that and making sure to maximize your billing whenever you can. ⁓ in real world, what this might look like is, ⁓ if you are doing a clinical interview, for example, and you push past an hour for that base code, ⁓
and you are trending toward another hour, well, if you have the decision to stop at 24 minutes versus as long as it’s necessary, of course, you can’t just invent ways to waste time. But as long as it’s necessary, spending an extra seven minutes to reach 31 minutes, which would allow you to bill for an additional unit. Like I said, it can definitely add up over time.
Dr. Jeremy Sharp (15:14)
So as we start to wrap up this discussion, again, there’s a lot more we could say here. I’m definitely not diving into audit triggers and things like that in any amount of detail. But I want to start to wrap up just by making sure that we talk about documentation. So billing appropriately is awesome. But if you don’t document it appropriately, you can still get denied during audits or other, you know,
questions from the insurance company. So to protect your practice, you need what I would call an audit ready log. And this means for every case, you should have some kind of documentation that lists the date of the service, the CPT code or codes, the start time and end time of that service, and a brief description of the service, like ⁓ scoring and or administration and scoring of the Waze 5, something like that. So why is this important? Because
Just because you bill a certain number of units that does not mean that the insurance company will believe you that you ⁓ Actually spent that time. So that’s what we’re doing here is we are documenting So if you bill six units of nine six one three three and the insurance company asks for your notes You have to show them those six hours of work You can’t just bill six hours with nothing there and you also can’t bill six hours for For an activity that doesn’t make sense, right so
You can’t really say that you did six hours of feedback. None of us really do that. So if your note just says, report, that’s going to be pretty vague, and they’re going to be suspicious. So you’ve got to document the complexity of your work, the thinking time, and then different ⁓ aspects of that code that you were performing. So in many cases, the good news is that your EHR is going to do this for you. ⁓
but you do have to make sure it’s set up correctly. And I will say this is one of those reasons that I love therapy notes and continue to use it. ⁓ It makes you document the time you spend on each activity to the minute in the default evaluation note template. Like this is just how it comes right out of the box. So you can set this up in other EHRs as well, of course, ⁓ but just make sure that you have those key components like I mentioned. And if your EHR doesn’t do this for you,
then you need something else like a spreadsheet or a face sheet or something that you fill out for each case that you do. You just have to make sure that you have this documentation somewhere. And our practice has been fortunate. We have not undergone many audits over the years, but we have passed every single one. Knock on one, because the documentation is in place.
All right, so in the next episode, we are going to talk more about scaling this insurance model by hiring a psychometrist, which uses the codes 96138 and 96139. We’re gonna look at the math of how you can kinda stay in the higher reimbursement professional work units and codes while somebody else handles the lower reimbursement administration codes. But until then, a little bit of homework. You can go back and take a look at your last five claims.
Dr. Jeremy Sharp (18:36)
And just even if they got paid, I mean, that’s great. If they got paid, that’s great. But just make sure you use the right evaluation codes to document or account for the time that you were spending. And you can also do a little survey of the time and the services that you’re doing during an evaluation. Check to see if you are eligible to bill some of those more obscure codes to capture some of the work you’re doing. Small changes, I think, can make a massive difference.
over time in your annual or even monthly revenue. right. So thanks for listening. We’ll see you next time.
Click here to listen to the podcast instead.