Clinical UM Guideline


Subject:  Psychological Testing
Guideline #:  CG-BEH-07Current Effective Date:  10/14/2014
Status:ReviewedLast Review Date:  08/14/2014

Description

This document addresses psychological testing. The medical necessity criteria outlined in this document for psychological testing include two categories; Severity of Illness and Intensity of Service. Severity of Illness criteria includes descriptions of the member's condition and circumstances. Intensity of Service criteria describes the services being provided.

Note: Please see the following related documents for additional information:

Clinical Indications

MedicallyNecessary:

Severity of Illness (SI)
Must have all of the following to qualify:

  1. Must be for the purpose of helping to establish the diagnosis of and to develop a treatment plan for a mental disorder, when this information is not adequately available from one or more comprehensive medical or behavioral health evaluations with the member and appropriate ancillary sources (e.g., family members, health care providers, school records); AND
  2. It should not be for the primary purpose of assessing learning disorders, vocational testing or educational planning, unless allowed by local plan clinical guidelines. Custody evaluation, court referral for evaluation (unless medically necessary) and testing for research purposes, are not covered;AND
  3. There is evidence to suggest that the testing results will have a timely and direct impact on the member's treatment plan.

Intensity of Service (IS)

  1. The services must be provided by a mental health provider who is licensed in their state of practice to do psychological testing.
  2. The provider's assessments, recommendations and reports are based on techniques sufficient to provide appropriate substantiation for their findings.  A select test battery is therefore employed and tailored to the specific referral question, rather than the use of a more standard, general battery.
  3. Brief rating scales, and standardized questionnaires administered by computer or those not requiring face-to-face administration can be done as part of a professional visit and should not be charged for separately.
  4. Only standardized tests that are based upon published national normative data, with scoring resulting in standardized or scaled scores, may be approved.
  5. Pre-surgical assessment or suitability for opioid therapy or spinal implant for pain management are limited to three hours (dependent upon plan benefits).
  6. The proposed time to administer selected tests should not exceed the administration time established by the tests' publishers, plus time necessary to score, interpret and report.

Note: Psychological testing for the purpose of assessing or screening members as part of a protocol for a surgical procedure (e.g., gastric by-pass surgery) or pain management program or to assess organic dysfunction related to a brain injury or brain damage is often covered as part of a comprehensive protocol or under the medical benefit. When this is not covered under the medical benefit, it should be reviewed by a physician/psychologist peer clinical reviewer.

Not Medically Necessary:

Psychological testing is considered not medically necessary when the above criteria are not met.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT 
96101Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI, Rorschach, WAIS), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report
96102Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI and WAIS), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face
96103Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI), administered by a computer, with qualified health care professional interpretation and report
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
 All diagnoses
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
 All diagnoses
Discussion/General Information

Psychological testing is a comprehensive battery of tests to assess self-concept, cognitive skills, or personality traits. Psychological testing is the responsibility of physicians and psychologists appropriately trained to perform and interpret test results, when this type of testing evaluation falls within their scope of professional practice. Testing can also be performed by other qualified health care professionals and/or through the use of a computer. There should be a reasonable expectation that the member's illness, condition, or level of functioning will be stabilized, improved, or maintained through treatment known to be effective for the member's illness.

Definitions

Psychological Testing: An objective and standard way of measuring an individual's mental or behavioral characteristics.

References

Peer Reviewed Publications:

  1. Frances A Docherty JP, Kahn DA. The expert consensus guideline series: treatment of bipolar disorder. J Clin Psychiatry. 1996; 5(Suppl 12A):1-88.
  2. McEvoy JP, Scheifler PL, Frances A. Treatment of schizophrenia 1999. The expert consensus guideline series. J Clin Psychiatry. 1999; 60 Suppl 11:3-80.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Child & Adolescent Psychiatry. Practice Parameters. Available at: http://www.aacap.org/cs/root/member_information/practice_information/practice_parameters/practice_parameters. Accessed on June 16, 2014.
  2. American Psychiatric Association. Clinical Practice Guidelines. Available at: http://www.psych.org/practice/clinical-practice-guidelines. Accessed on June 16, 2014.
  3. American Society of Addiction Medicine Treatment. Available at: http://www.asam.org/research-treatment/treatment. Accessed on June 16, 2014.
  4. Depression in Primary Care: Detection and Diagnosis. Volume 1. Detection and Diagnosis Clinical Guideline Number 5. AHCPR Publication No. 93-0550: April 1993.
  5. Manual of Psychiatric Peer Review (1974). American Psychiatric Association.
  6. Mattson M. Manual of psychiatric quality assurance: American Psychiatric Association committee on quality assurance. 1st ed. Arlington: American Psychiatric Publishing. 1992.
  7. Treatment of Major Depression. Volume 2. Treatment of Major Depression Clinical Practice Guideline Number 5. AHCPR Publication No. 93-0551: April 1993.
Index

Psychological Testing

History

Status

Date

Action

Reviewed08/14/2014Medical Policy & Technology Assessment Committee (MPTAC) review.
Reviewed08/08/2014Behavioral Health Subcommittee review. Updated Description, Discussion/General Information and References.
New08/08/2013MPTAC review.
New07/26/2013Behavioral Health Subcommittee review. Initial document development. Initial document development. Updated Clinical Indications Severity of Illness, #1 added the word "medical" to the evaluations. Updated References. The Behavioral Health Medical Necessity Criteria effective January 1, 2013 was split apart into specific subject matter clinical UM guidelines.