CPT 96130 Frequently Asked Questions

CPT 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”

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 Non-Clinical Social Workers cannot bill 96130.

No, You don’t have to be a behavioral health provider to bill 96130.

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, PhD, PsyD, ETC.

Medicare: Requires mental health related ICD10 codes (generally codes beginning in F) or codes for symptoms related to mental health conditions – refer to the latest Medicare Billing and Coding Articles for the exact covered codes.

Major Medical: Depending on the specific mental health coverage in a patient’s insurance plan there are 2 approaches to choosing ICD-10 codes.

1. If the patient’s insurance plan covers mental health, then bill using mental health related ICD10 codes (generally codes beginning in F).
2. If the patient’s insurance plan does not cover mental health, then bill using ICD10 codes for conditions/ symptoms comorbid to mental health. For example, depression and anxiety are comorbid to diabetes, and it is the standard of care to test for both when treating diabetes. The ICD10 code for diabetes would justify the administration in most circumstances.

Note: Make sure that you do not use the same ICD10 codes to justify your E&M as you use to justify 96130 or the insurance company will consider 96130 as bundled and will not pay.

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. For more detailed information download our latest billing guide.

CPT code 96130 is a time-based code and is for the first hour of testing evaluation services performed. A minimum time of 31 minutes must be used to count as 1 hour.

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)

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.

96130 may be billed as often as medically necessary. Although CMS does not have a restriction, some insurances will restrict the number of times per year 96130 may be billed. Please check with the insurance company for their particular restrictions.

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.

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

As of January 2024 the average Medicare reimbursement rate for 96130 is $118.53.

As of January 2024 CPT 96130 has been approved by CMS for use with telemedicine, including audio only, through December 31, 2024.