Clinical UM Guideline


Subject:  Psychological Testing
Guideline #:  CG-BEH-07Current Effective Date:  10/08/2013
Status:NewLast Review Date:  08/08/2013

Description

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

This document addresses psychological testing.

Please see the following related document(s) 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 Covered Individual 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 Covered Individual'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 (3) 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 Covered Individuals 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.  A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference.  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 
 All diagnoses
  
ICD-10 DiagnosisICD-10-CM draft codes; effective 10/01/2014:
 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 to be performed by clinicians (for example, physicians, psychologists), appropriately trained to perform and interpret test results, when this type of testing evaluation falls within their scope of professional practice. There should be a reasonable expectation that the Covered Individual's illness, condition, or level of functioning will be stabilized, improved, or maintained through treatment known to be effective for the Covered Individual's illness.

It is noted that there is variation in the availability of services in different geographic and regional areas. If an indicated service is not available within a Covered Individual's community at the level of service indicated by the criteria, authorization may be given for those services at the next highest available level.

Definitions

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

References

Peer Reviewed Publications:

  1. Kahn, DA, Carpenter D, Docherty JP, Frances A. (1996): The expert consensus guideline series: treatment of bipolar disorder. J Clin Psychiatry, 57 (Suppl 12A).
  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 April 26, 2013.
  2. American Psychiatric Association. Clinical Practice Guidelines. Available at: http://www.psych.org/practice/clinical-practice-guidelines. Accessed on April 26, 2013.
  3. American Society of Addiction Medicine Treatment. Available at: http://www.asam.org/research-treatment/treatment. Accessed on April 26, 2013.
  4. Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. DHHS Publication No. (SMA) 05-4048. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005.
  5. Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS Publication No. (SMA) 07-3939. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2004.
  6. Depression in Primary Care: Detection and Diagnosis. Volume 1. Detection and Diagnosis Clinical Guideline Number 5. AHCPR Publication No. 93-0550: April 1993.
  7. Fishman MJ, Shulman GD, Mee-Lee D, et al. ASAM patient placement criteria: supplement on pharmacotherapies for alcohol use disorders. 1st ed. Philadelphia: Lippincott Williams & Wilkins. 2010.
  8. Hoffman NG, Mee-Lee D, Halikas JA. Patient placement criteria for the treatment of psychoactive substance use disorders. Chevy Chase: American Society of Addiction Medicine. 2001.
  9. Manual of Psychiatric Peer Review (1974). American Psychiatric Association.
  10. Mattson M. Manual of psychiatric quality assurance: American Psychiatric Association committee on quality assurance. 1st ed. Arlington: American Psychiatric Publishing. 1992.
  11. Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment. Intensive outpatient treatment for alcohol and other drug abuse. 1994. DHHS Publication No. (SMA) 94B2077.
  12. Treatment of Major Depression. Volume 2. Treatment of Major Depression Clinical Practice Guideline Number 5. AHCPR Publication No. 93-0551: April 1993.
  13. Weiner RD. Manual of psychiatric quality assurance. 1st ed. Arlington: American Psychiatric Publishing. 1992. Electroconvulsive therapy guidelines and criteria.
  14. Weiner RD. Practice of electroconvulsive therapy: recommendations for treatment, training, and privileging (A task force report of the American Psychiatric Association). 2nd ed. Arlington: American Psychiatric Publishing. 2001.
Index

Psychological Testing

History

Status

Date

Action

New08/08/2013Medical Policy & Technology Assessment Committee (MPTAC) 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.