CPT 96130 Frequently Asked Questions

by | Jun 10, 2021

What is CPT 96130?

96130 is defined as “psychological testing evaluation services by physician or other qualified healthcare professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member or caregiver, when performed; first hour”

Who can bill CPT 96130?

A physician or other qualified healthcare professional may bill 96130. For example a Family Practice MD, an Internal Medicine PA, a Pediatric NP, or a Licensed Clinical Psychologist. A behavioral health specialty is not required. Therapists and Social Workers cannot bill 96130.

Do I have to be a behavioral health specialist to bill CPT 96130?

No, you don’t have to be a behavioral health specialist to bill 96130.

Can the work for CPT 96130 be delegated to a technician?

No. 96130 cannot be delegated to a technician. The services must be performed by a physician or other qualified healthcare professional. Such as an MD, DO, PA, NP, LCP.

Is 96130 time based?

CPT code 96130 is a time-based code and is for the first hour of testing evaluation services performed.

How much time must be spent to bill CPT 96130?

The minimum time that can be spent and still bill CPT 96130 is 31 minutes (1/2 the defined time plus one minute: 1 Hour/ 2 + 1 = 31 minutes)

What if CPT 96130 evaluation time exceeds one hour?

If evaluation time for 96130 exceeds one hour you may bill each additional hour by using CPT 96131. For example if testing evaluation services takes 3 hours to complete you would bill 96130 and 96131 with 2 units.

What does the time requirement for CPT 96130 include?

The time requirement to bill 96130 includes integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and face time with the patient. Face time with the patient must include interactive feedback to the patient, family member or caregiver.

Does CPT 96130 services need to be performed on the same day as 96136 or 96138?

No. 96130 services may be performed on a separate day from CPT 96136 or CPT 96138.

How many times per year can I bill CPT 96130?

96130 may be billed as often as medically necessary. Some insurances will restrict the billing to no more than once per year. Please check with the insurance company for their particular restrictions.

How much does CPT 96130 pay?

As of January 2021 the average Medicare reimbursement rate for 96130 is $122.

Can I bill CPT 96130 with Telemedicine?

CPT 96130 has been approved by CMS for use with telemedicine at least through the end of 2021.

What modifier should I use when billing CPT 96130?

When 96130 is billed with an E&M code, the E&M code should be billed first with a modifier 25. 96130 should be billed last with a modifier 59.

Learn about more mental health billing codes: Request our Billing/ Coding Sheet