How To Use CPT Code 96138

CPT 96138 refers to the administration and scoring of two or more psychological or neuropsychological tests by a technician, covering the first 30 minutes. This article will discuss the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 96138.

1. What is CPT 96138?

CPT 96138 is a medical billing code used to describe the administration and scoring of two or more psychological or neuropsychological tests by a technician. This code is specifically used for the first 30 minutes of test administration and scoring, regardless of the method used. The purpose of these tests is to assess various psychological functions and their relation to specific brain structures or pathways.

2. 96138 CPT code description

The official description of CPT code 96138 is: “Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; first 30 minutes.”

3. Procedure

1. The technician explains the tests to the patient, parent, and/or guardian and answers any questions they may have.
2. Tests are administered by the technician using any method, including standardized psychological tests (e.g., personality tests, attitude tests, IQ tests, achievement tests) or neuropsychological tests designed to measure specific psychological functions linked to particular brain structures or pathways.
3. The technician scores the tests.
4. For each additional 30 minutes of test administration and scoring, CPT code 96139 should be reported in addition to the primary code.

4. Qualifying circumstances

Patients eligible to receive CPT 96138 services are those who require psychological or neuropsychological testing for various reasons, such as assessing cognitive functioning, diagnosing mental health disorders, or evaluating the effectiveness of treatment interventions. The tests must be administered by a qualified technician under the supervision of a licensed psychologist or neuropsychologist.

5. When to use CPT code 96138

It is appropriate to bill CPT 96138 when a technician administers and scores two or more psychological or neuropsychological tests for the first 30 minutes. This code should be used regardless of the method of test administration, as long as the tests are conducted by a qualified technician under the supervision of a licensed psychologist or neuropsychologist.

6. Documentation requirements

To support a claim for CPT 96138, the following information should be documented:

• Patient’s demographic information, including name, date of birth, and insurance information.
• Reason for the testing, such as diagnostic evaluation, treatment planning, or monitoring of treatment progress.
• Specific tests administered and their respective scores.
• Duration of test administration and scoring, including start and end times.
• Qualifications of the technician administering and scoring the tests.
• Supervising psychologist or neuropsychologist’s information, including name, credentials, and contact information.

7. Billing guidelines

When billing for CPT 96138, it is important to follow these guidelines:

• Report CPT 96138 for the first 30 minutes of test administration and scoring.
• For each additional 30 minutes, report CPT 96139 in addition to the primary code.
• Ensure that all required documentation is complete and accurate to support the claim.
• Verify that the technician administering and scoring the tests is qualified and working under the supervision of a licensed psychologist or neuropsychologist.

8. Historical information

CPT 96138 was added to the Current Procedural Terminology system on January 1, 2019. There have been no updates to the code since its addition.

9. Similar codes to CPT 96138

Five similar codes to CPT 96138 include:

1. CPT 96130: Psychological testing evaluation services by a psychologist or physician, first hour.
2. CPT 96131: Psychological testing evaluation services by a psychologist or physician, each additional hour.
3. CPT 96132: Neuropsychological testing evaluation services by a psychologist or physician, first hour.
4. CPT 96133: Neuropsychological testing evaluation services by a psychologist or physician, each additional hour.
5. CPT 96139: Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; each additional 30 minutes.

10. Examples

Here are 10 detailed examples of CPT code 96138 procedures:

1. A technician administers and scores an IQ test and a personality test for a patient referred for diagnostic evaluation.
2. A patient undergoing treatment for depression receives a series of psychological tests to monitor treatment progress, administered and scored by a technician.
3. A child with suspected learning disabilities is given a battery of achievement tests and an IQ test, administered and scored by a technician.
4. A patient with a traumatic brain injury undergoes neuropsychological testing to assess cognitive functioning, with tests administered and scored by a technician.
5. A technician administers and scores a series of attitude tests and personality tests for a patient referred for pre-employment screening.
6. A patient with suspected dementia receives a battery of neuropsychological tests to assess cognitive decline, administered and scored by a technician.
7. A technician administers and scores a series of psychological tests for a patient referred for a forensic evaluation.
8. A patient with a history of substance abuse undergoes psychological testing to assess treatment needs, with tests administered and scored by a technician.
9. A child with suspected autism spectrum disorder receives a series of psychological tests to assess social and communication skills, administered and scored by a technician.
10. A patient with a history of seizures undergoes neuropsychological testing to assess cognitive functioning, with tests administered and scored by a technician.