Does anyone have experience billing code 96101, psychological testing?

sfoster 8 years ago in Codes/Rates/Diagnosis Modules updated by Richard Sethre, Psy D , L P. 8 years ago 13

Does anyone have experience billing code 96101, psychological testing?

One of our staff also bill out the 96101

We use 96101 for billing

I have billed with 96101, 96102, 96103, 96150 and 96127. . I also used to work as a consultant for a managed care company, and am familiar with both CMS and managed care guidelines for billing for psychological testing. Feel free to post specific questions about billing issues for testing. Also, there is a fantastic online resource provided by the President-Elect of the American Psychological Association, Tony Peunte, Ph.D., about CPT coding and billing issues. See: http://psychologycoding.com/downloads/ He provides slides from his presentations and also access to webinars.

yes, we've billed it before. most insurance plans require a pre auth. some plans only authorize 2-3 units of testing, so our provider who does testing would charge $130/unit or hour as private pay above and beyond what insurance pays/authorizes.

Crystal, We have been told that you cannot bill a client privately for any services that the insurance company did not approve, that you have to accept the insurance payment only and cannot bill the client directly? Does anyone else have an opinion on this?

Since our provider is spending much more than 2 or 3 hours of testing and feedback, that is what we have done, however, he makes the contract with the private pay agreement with the client BEFORE actually doing the testing. If insurance only authorizes 3 units, we only bill 3 units to insurance, nothing more because we know they will deny it.

Most or all insurance companies don't approve/pay for couples/marriage, so our therapists bill private pay for those clients who wish to receive this type of counseling.

Crystal wrote, "Most or all insurance companies don't approve/pay for couples/marriage." That has not been my experience at all in MN - in fact, I am not aware of any major MCO who does not over 90847/90846. There may be exceptions to this if the patient/client has a contract, such as one through an employer, that specifically excludes 90847/90846 as a covered benefit, but this is, at least in my experience, rare.

In fact, in my experience, most MCOs not only cover 90847/90846 but also pay at a higher rate than the standard therapy code, 90834.

On the other hand, 90847/90846 may be a covered benefit, but there are still some challenges for billing for it: you have to select one person as the "identified patient," and that person has to have symptoms/impairments that support at least one diagnosis that establishes the medical necessity for your 90847/90846 services.

When in doubt, call the MCO in question to verify benefits.

Greetings to Paula, Crystal and other group members interested in this discussion:

You can indeed bill the patient/client for any service that is not a covered benefit, but this must be done with a signed wavered of understanding. This could apply to services that are not a covered benefit, such as academic achievement or learning disorder testing, or a prior authorization request that has been denied, or partially authorized. For example, one company does not cover testing for pre-surgery bariatric assessments. Or, another company may authorize only 2 hours of a request for authorization for 4 hours. It would be necessary to obtain a waver signed by the patient in order to bill for these services.

You would need to discuss the situation with the patient and have them sign a form documenting that they understand that they will be billed for a service that is not covered by their insurance. This would need to include the fee that you will charge for the service. I usually charge what my contracted fee with their insurance company- what I would have been paid by insurance, if they did actually pay.

BCBS of MN has a template waver form somewhere on their website, but it is hard to locate. I have a saved version and would be glad to share it, so feel free to contact me backchannel at drsethre@mhconcierge.com

I have never had a problem with doing this, but if in doubt it would be advisable to contact each of your contracted MCOs to verify that this type waver is permitted by contact.

I am concerned about the phrase "covered benefit". Most insurance companies consider a 96101 a covered benefit, some needing a pre-auth prior to testing, When billing the covered benefit, I am still understanding that we must accept the payment received by insurance and not bill the client directly for anything that the covered benefit did not pay for. I understand that there are waiver forms available, but I believe those are for only when a 96101 is not a covered benefit on the individuals insurance policy and that we may then bill the client directly.

We would like to bill the client directly for anything unpaid, as the LP's certainly do not get reimbursed by insurance companies for all of their time put into the assessing, interpreting and report writing. If anyone has anything in writing , from an insurance company, stating that we can bill a client for a covered benefit, in which we did not receive enough compensation, please forward it to me.

You have make a distinction be "a covered benefit" (something that the MCO pays for) and "contracted reimbursement for a covered benefit" (how much they pay). You absolutely may not bill the pt for more than your contracted rate for a covered benefit when you receive payment for a service. This would be, frankly, billing fraud.

On the other hand, if a "covered benefit" is denied as not medically necessary, it is my understanding that you MAY bill the pt, but you MUST have a waver signed. And, same for applies for non-covered services.

Here are links to "something in writing" from BCBS MN:

Here is the link to the current (as of 12-8-16!) BCBS Provider Manual


The manual states:

A sample waiver for use in Provider's office is available on Blue

Cross' website. The waivers include the information required in

order for Provider to hold the Subscriber financially liable for

services. The waiver should be incorporated into Provider's usual

business forms and should be customized to include Provider's

business letterhead.

Here is the link to the sample waver form.


Scroll down to the "Sample waver form," which includes guidelines for when a waver is needed.

This clearly indicates that it is possible for BCBS MN providers to bill Subscribers for non-covered services, with a properly signed waver. I don't have time to provide this info for all MN MCOs, but if in doubt you could call the provider relations office for a few of them and see what they say about use of a waver to bill a Subscriber for "non-covered" services (either a covered benefit which has been denied as not medically necessary or a non-covered benefit).

So if a Wisc or Wais may be clinically relevant but not medically necessary, using a waiver, we could bill the client directly for these assessments? Also, it sounds like the additional hours spent on pysch evals, when you have been only pre- approved for 2-3 units, you could bill the client, if you have a waiver in place?

Yes, that is my understanding on both - but I would confirm this with the MCO, if in doubt. This is, of course, a hassle that will take some time, but I think it would be worth it in order to increase your reimbursement.