CPT 96138 is defined as “Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; first 30 minutes.”
No, You don’t have to be a behavioral health provider to bill 96138.
A physician or other qualified healthcare professional may bill 96138. 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 96138.
Yes. 96138 is specifically for billing when a test administration is conducted by a technician. If test administration is performed by a qualified healthcare provider then you should bill using CPT 96136.
Medicare: Requires mental health related ICD10 codes (codes beginning in F) or codes for conditions/ symptoms comorbid 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 (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 96138 or the insurance company will consider 96138 as bundled and will not pay.
When 96138 is billed with an E&M code, the E&M code should be billed first with a modifier 25. 96138 should be billed last with a modifier 59. For more detailed information download our latest billing guide.
CPT code 96138 is a time-based code and is for the first 30 minutes of testing administration services performed. A minimum time of 16 minutes must be used to count as 30 minutes.
The minimum time that can be spent and still bill 96138 is 16 minutes (1/2 the defined time plus one minute: 30 minutes/ 2 + 1 = 16 minutes)
The time requirement to bill 96138 includes test administration and scoring by technician, two or more tests, any method; first 30 minutes.
If test administration time for 96138 exceeds 30 minutes you may bill each additional 30 minutes by using CPT 96139. For example if testing evaluation services takes 1.5 hours to complete you would bill 96138 and 96139 with 2 units.
96138 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 96138 may be billed. Please check with the insurance company for their particular restrictions.
As of January 2023 the average Medicare reimbursement rate for 96138 is $33.86.
No. 96138 services may be performed on a separate day from CPT 96130.
As of January 2023 CPT 96138 has been approved by CMS for use with telemedicine, including audio only, through December 31, 2023.