CPT 96103 Billing and Usage Guide
UPDATE: As of January 1, 2019 CPT code 96103 has been retired. Please see the article “New CPT Codes for Psychological Testing and Evaluation” for the latest information.
What is CPT Code 96103?
CPT Code 96103 is a computer administered, computer graded, psychologic assessment, overseen by a qualified healthcare provider. A qualified healthcare provider may include, but is not limited to psychiatrist or other mental health professional. Because of the comorbidities between mental health conditions and physical medicine it has become more important that primary care and other specialties have the tools to accurately diagnose patients to determine if their conditions are affected by, or caused by an underlying mental health condition, such as depression. The CPT code 96103 ensures that primary care providers, and specialists are reimbursed for the use of those tools.
Although, it is a grey area, CPT 96103 was not intended for use with computerized paper based instruments, such as the PHQ-9 or CES-D. Those instruments fall more in line with the screening CPT code 96127. CPT code 96103 was intended for use with more sophisticated instruments that were specifically designed to be administered by a computer, such as an instrument utilizing a branching logic engine. The higher reimbursements commanded by CPT 96103 are due to the higher level of detail computer based assessments provide.
When billing for CPT code 96103, providers will need to document medical necessity to justify the administration of the computer based psychological assessment. This can include anything from the administration of a new drug, to stomach pain, to insomnia, so long as there are clear comorbidities between the patient’s condition and the potential mental health condition that the provider wants to include or eliminate with the assessment.
Can I bill CPT code 96103 with 96127?
Each insurance is different. Please check with each insurance provider for specific guidelines.
CMS will not cover both CPT 96127 and CPT code 96103 in the same visit and considers the codes as bundled services. Some major medical sees CPT 96127 and CPT code 96103 as separate services and will pay for both in the same visit.
When can I bill for 96103?
Provided that there is medical necessity, CPT code 96103 may be billed once per encounter, regardless of the number of assessments administered. As of January 2015, average reimbursement rates ranged between $27 and $55, depending on the payor. CPT 96103 should not be billed more often than every 2 weeks. CPT code 96103 is reimbursed by Medicare, and most major medical. It is important to review each insurer’s specific guidelines.
Use modifier 59 with CPT code 96103?
Each insurance is different. Some insurance require modifier 59 and others modifier 25.
Please check with each insurance provider for specific guidelines.
Under certain circumstances, a physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician.
Most payers may require that modifier 59 is appended to the CPT 96103.
NOTE: Modifier 25 should be appended to the E/M and modifier 59 should be appended to the 96103 CPT code.
Please see the CMS documentation for additional information and circumstances: