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A psychology practice bills three streams of income under different guidelines. Psychotherapy sessions are billed by units of time. Evaluation and administration layers are used for billing of multi-hour testing batteries. Health behavior assessment is billed under medical diagnosis code. We provide all three streams, using unit-based authorizations and Medicare billing guidelines tailored specifically for clinical psychology. This is psychological medical billing services based on the psychologist’s license.
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Medicare reimbursement rate for clinical psychologists, not a percentage
The code series for psychological testing, which brings in most psychologist income and denials
The Medicare code for clinical psychologist enrollment
PSYPACT members, where practice authority is not tied to enrollment
Psychology billing involves coding and claims for both PhDs and PsyDs. This entails diagnosis codes for 90791, psychotherapy, and psychological and neuropsychological testing from 96130 through 96139. Health behavior assessment and intervention is included. So too are the authorizations based on units and Medicare guidelines for clinical psychologists.
Psychologist licensure determines which codes are used. Psychologists control the test evaluation codes that master’s-level clinicians are prohibited from billing. Psychologists bill 90791 for their intake and not 90792. They are also forbidden from using Medicare evaluation and management codes. Testing represents the income that distinguishes psychology practices from counseling practices, along with denial danger.
There are four points that distinguish the process of psychology billing from all other behavioral health licenses. Medicare pays the entire fee schedule to psychologists. Psychologists are not allowed to use evaluation and management codes. The code for the initial visit is 90791, not 90792. Tests are the place to earn and to get denied. All four points influence the way a psychology claim is constructed.
Clinical psychologists are paid 100% of the Physician Fee Schedule by Medicare. The clinical social workers are paid at 75% of the rate for psychologists. There is no incident-to billing for psychologists in Medicare. Full rate makes the difference in the way commercial plans should reimburse.
A psychologist cannot bill any Medicare evaluation and management codes. This is our structural line between psychology and psychiatry, where E/M coding is done with a psychotherapy code as an add-on. Some RxP states allow psychologists to prescribe medication.
Psychologists bill 90791 for their diagnostic intake service. Psychologists do not bill 90792, which covers some medical services performed by the prescriber only. Some available literature may be incorrect regarding this aspect for psychologists.
As part of psychology billing, the money is in tests; the same is true of denials. A test involves more codes, more units, and more rules than a therapy session does. Routing of tests as carve-outs is a key theme and is addressed under the behavioral health billing section.
The point to keep in mind is that in psychology billing, the money is in the tests, and so are the denials. A practice that can code the testing levels properly secures the money side of its business.
Testing billing splits into two separate code layers. Evaluation codes cover the psychologist’s interpretation, integration, and report time. Administration codes cover the face-to-face testing time. Administration then splits by who performed it, the psychologist or a technician. Mixing these layers is the top psychology-specific denial, and the codes below show why.
Psychological testing evaluation performed by the psychologist. Involves integration, interpretation, and reporting.
First hour, then each additional hour. First hour, then each additional hour. A 31-minute minimum starts the first unit.
Neuropsychological testing evaluation. Same as above but restricted to neuropsychological assessment. First hour, then each additional hour. Insurance companies do not include neuropsychology under psychology.
Administration and Scoring of psychological testing by the psychologist/QHP. Administration and scoring of two or more tests using any format. First 30 minutes, then each additional 30. 16 minute minimum for the first unit.
Testing administration and scoring by a technician under the supervision. Layer competitors misinterpret.
First 30 minutes, followed by 30 minute increments thereafter. Billed under the supervising psychologist’s NPI.
Test administration by automated equipment only, with automated results.
Single device only. Not used in multiple devices testing where codes 96136 or 96138 are billed.
Neurobehavioral status examination. Evaluation of thought processes, reasoning, and judgment.
First hour, followed by one hour increments thereafter.
Developmental test administration including evaluation of tests.
First hour, followed by 30 minute increments thereafter.
Short emotional/behavioral assessment using standardized instruments.
Per instrument. May not be reported on the same day as codes 96136, 96138 or 96130.
Confused about whether your testing statements have been properly coded to the appropriate levels?
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Health behavior assessment and intervention billing codes compensate psychologists for treatment associated with a physical illness. It is essential that the principal diagnosis be a medical and not a psychiatric one. These codes have been updated from the earlier health and behavior category in 2020. Psychology practices rarely use them, leaving out a legitimate revenue stream.
HBAI deals with the psychological aspects associated with the physical illness. The assessment code is 96156, an undetermined time evaluation. Individual intervention has a code 96158 with an add-on 96159. Group intervention involves 96164 and 96165. Family intervention with the patient present involves 96167 and 96168.
HBAI demands a diagnosis of physical health as the primary ICD-10 code. The submission of a DSM diagnosis in that place leads to denial of the claim. The treatment concerns coping, adherence, and adjustment to a physical disease. It is not mental health care, nor can it be billed on the same day as psychotherapy.
Most HBAI applications come from integration and health psychology services. The patient with cancer suffering with adherence is a good example. Same for the post-bariatric patient, chronic pain patient, or a cardiac patient. The referral starts from a physical diagnosis, but the psychological components delay the healing process.
The most frequent reason for HBAI claim denial is the psychiatric diagnosis coded as primary. The payers see it as an improper coding for the provided service and deny it. In the context of Medicare, HBAI billing is limited to the specialty of clinical psychologists. We check the diagnosis structure before sending the claim.
Psychologists have a shared code set for psychotherapy with all the other licenses. The intake code is 90791. Individual therapy is billed by time under 90832, 90834, and 90837. There are separate codes for family and group work. These are the codes in which a claim from the psychology license appears just like any other, and the elaboration on them can be found on the sibling pages.
Shared psychotherapy and diagnostic codes
| Codes | What We Handle |
|---|---|
|
90791 |
Psychiatric diagnostic evaluation, the psychologist intake. Never 90792. |
|
90832 / 90834 / 90837 |
Individual psychotherapy, 16 to 37, 38 to 52, and 53+ minutes. |
|
90853 |
Group psychotherapy, per member per session. |
|
+90785 |
Interactive complexity add-on, when there is communication difficulty in the session. |
|
96127 |
Brief behavioral assessment per instrument, separate from the testing battery. |
This elaboration on the codes takes place on the pages for these licenses. Master’s level psychotherapy coding is more extensive on our counseling billing and clinical social work billing pages. This page purposely keeps the set brief. The unique revenues of the psychologist lie above in the testing and HBAI work.
Billing of telepsychology is done using the place-of-service code and, for most payers, modifier 95. PSYPACT is an agreement which allows a licensed psychologist to practice across state lines in member states. However, authorization to practice is not enrolment. A licensed psychologist may be authorized to practice telepsychology in one state but not be enrolled with the payer.
A telehealth service has place-of-service 10 if the service is delivered from the comfort of the client's home, while 02 if the patient is somewhere else. Many payers require use of modifier 95 in the bill. Requirements of coverage and modifier vary from payer to payer. The claim could be denied when billed using the office place-of-service code. We have matched the place of service with the location of the patient.
PSYPACT is an interstate compact involving more than 40 states. PSYPACT authorizes the delivery of telepsychology and limited temporary in-person services for licensed psychologists in member states. PSYPACT solves the problem of authorization to practice when the patient happens to be in another compact state.
There is a distinction between PSYPACT authority and payer enrollment. Being authorized to practice under the compact allows you to practice in that state as long as it is a member of the organization. It will not enroll you under that state’s Medicaid or commercial payers.
Both Testing and HBAI billing fall into a bigger cycle. Credentialing must contain the proper Psychologist Taxonomy. Eligibility must verify the benefit of testing prior to battery. Prior authorization, denial management, and AR follow-up all have their own psych components. We complete the whole cycle around the Psychologist License.
Enrollment under specialty code 68 with the appropriate 103TC0700X taxonomy in all systems.
Verification of testing benefit prior to multi-hour battery so that we verify benefit before work is done.
Unit-based testing authorizations requested, followed up on, and renewed before units expire.
Denials of layer mixing and unit expiration appeals processed by CARC reason code.
Enrollment under specialty code 68 with the appropriate 103TC0700X taxonomy in all systems.
The whole revenue cycle is integrated, starting with credentialing and ending with payment posting.
We bill psychological practices across all 50 states. There is variation across states in PSYPACT membership, and also Medicaid coverage for psychological testing. State licensing boards have different title laws as well. The following are state-specific rules for psychological testing and telepsychology.
| State | Psychology Billing Services |
|---|---|
|
California |
Filing guidelines vary with Medi-Cal county plans. The prompt-pay law in California applies pressure on payers to do something about clean claims. |
|
Texas |
PSYPACT member state. Every STAR MCO has its own testing authorization process and cap. |
|
New York |
Psychological testing coverage exists via Medicaid managed care organizations. PSYPACT status is now uncertain and requires verification. |
|
Florida |
PSYPACT Member State. Medicaid MMA plans provide for testing according to their own unit-based criteria. |
|
Georgia |
PSYPACT Member State. Georgia Families CMOs establish their own criteria for testing authorization and neuropsychology. |
|
Tennessee |
TennCare operates only through MCOs with varying timely filing windows. Each claim is filed through a managed care plan. |
|
Arizona |
PSYPACT Member State. AHCCCS provides for testing coverage by its regional behavioral health plans. |
|
New Hampshire |
PSYPACT Member State. Managed care of Medicaid provides for testing authorization by plans. |
|
Mississippi |
PSYPACT Member State. Testing authorization occurs according to coordinated care organization’s criteria. |
|
Washington |
PSYPACT Member State. Apple Health managed care provides for testing coverage under unit criteria. |
|
New Jersey |
PSYPACT Member State. NJ FamilyCare MCOs establish testing authorization and coverage criteria. |
|
Illinois |
PSYPACT Member State & RxP state for prescribing psychologists. Medicaid MCOs establish their own criteria for testing. |
|
Pennsylvania |
PSYPACT Member State. Behavioral MCOs of HealthChoices establish their own criteria for testing. |
|
Massachusetts |
Testing coverage occurs according to MassHealth plans. PSYPACT membership should be verified prior to multi-state practice. |
Looking for a psychologist/psychological testing practice in the metro area? We charge for psychological practices in New York City, Los Angeles, Chicago, Houston, Dallas, Phoenix, Philadelphia, San Diego, Miami, Atlanta, Boston, Seattle, Denver, Washington DC, the Bay Area, Minneapolis, Charlotte, Nashville, Austin, Detroit, Tampa, and Columbus. We are nationally licensed, meaning no state can restrict our services.
For interpretation and report, psychologists use the evaluation codes 96130 and 96132. For testing per se, they use the administration codes 96136 and 96138, each of which has a time add-on. Codes 96138 and 96139 are used if testing is performed by a technician supervised by the psychologist.
No. The diagnostic evaluation is billed using the 90791 code, and not 90792 because the latter includes medical services that can be provided by the prescriber only. Psychologists are not allowed to bill Medicare E/M codes either. There are several RxP states where psychologists are allowed to prescribe. These include New Mexico and Louisiana.
Yes, Medicare pays for the work of the clinical psychologist at 100% of Physician Fee Schedule rate. The clinical social worker is reimbursed for the same work at 75% of the rate for psychologists. Psychologist works under the specialty code 68 and bills independently without any incident-to billing for his own services.
No. Generally, commercial payers do not cover testing for educational purposes such as a learning disability test for educational placement. Custody and forensic evaluations do not qualify for health insurance billing because of their non-medical nature. They are mostly privately billed arrangements.
HBAI codes compensate the psychologist for services that are associated with a physical condition, such as cancer or chronic pain. The principal diagnosis has to be based on medicine, not psychiatry. The list includes 96156 for evaluation and 96158 with 96159 for individual intervention. They cannot be billed on the same day as psychotherapy.
Yes. Testing administered by technicians bills at 96138 and 96139, which are the technician administration codes. It is billed using the NPI of the psychologist who supervised the tests. Supervision rules differ depending on the insurance company and Medicare carrier. The supervision rule is always validated for each specific payer before billing.
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