Local Coverage Determination (LCD): Psychological and Neuropsychological Tests (L33688)

Transcription

1 Local Coverage Determination (LCD): Psychological and Neuropsychological Tests (L33688) Contractor Information Contractor Name First Coast Service Options, Inc. Document Information LCD ID L33688 LCD Title Psychological and Neuropsychological Tests Original Effective Date For services performed on or after 10/14/2013 AMA CPT/ADA CDT Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. Revision Effective Date For services performed on or after 10/14/2013 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date 08/30/2013 Notice Period End Date 10/14/2013 CMS National Coverage Policy Language quoted from CMS National Coverage Determination (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR [b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See 1869(f)(1)(A)(i) of the Social Security Act.

2 Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: CMS Manual System, Pub , Medicare Benefit Policy Manual, Chapter 15, Section 80.2 Psychological Tests and Neuropsychological Tests, and Sections Clinical Psychologists and Clinical Social Worker (CSW) Services CMS Manual System, Pub , Medicare Program Integrity, Chapter 3, Section Psychotherapy Notes CMS Medicare Learning Network, March 2012, Mental Health Services (accessible at: MLN/MLNProducts/downloads/Mental_Health_Services_ICN pdf) National Correct Coding Initiative Policy Manual for Medicare Services NCCI), Chap 11, section M Central Nervous System Assessments/Tests Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity Neuropsychological tests provide measurements of brain function that are objective, valid, and reliable. Neuropsychological tests are quantifiable in nature and require patients to directly demonstrate their level of cognitive competence in a particular cognitive domain. Neuropsychological tests are administered in the context of a comprehensive assessment that synthesizes data from clinical interview, record review, medical history, and behavioral observations. Information from neuropsychological assessments directly impacts medical management of patients by providing information about diagnosis, prognosis, and treatment of disorders that are known to impact central nervous system (CNS) functioning. In addition, neuropsychological assessments predict functional abilities across a variety of disorders. Indications for neuropsychological assessments include a history of medical or neurological disorder compromising cognitive or behavioral functioning; congenital, genetic, or metabolic disorders known to be associated with impairments in cognitive or brain development; reported impairments in cognitive functioning; and evaluations of cognitive function as a part of the standard of care for treatment selection and treatment outcome evaluations (e.g., deep brain stimulators, epilepsy surgery). Neuropsychological assessments are not limited in relevance to patients with evidence of structural brain damage, and are frequently necessary to document impairments in patients with probable neuropsychological and neurobehavioral disorders, and are the tool of choice whenever objective documentation of subjective cognitive complaints and symptom validity testing are indicated. In children and adolescents, a significant inability to develop expected knowledge, skills or abilities as required to adapt to new or changing cognitive, social, emotional, or physical demands warrants a neuropsychological evaluation. Neuropsychological testing is not supported or excluded from medical necessity based on diagnosis alone. Rather, indications for testing are based on whether there is known or suspected neurocognitive involvement or effects, or where neuropsychological testing will impact the management of the patient by confirmation or delineation of diagnosis, or otherwise providing substantive information regarding diagnosis, treatment planning, prognosis, or quality of life. Neuropsychological testing is useful in persons with documented changes in cognitive function to differentiate neurologic diseases (i.e., one of the types of dementia) or injuries (e.g., traumatic brain injury, stroke) from depressive disorders or other psychiatric conditions (e.g., psychosis, schizophrenia) when the diagnosis is uncertain after complete neurological examination, mental status examination, and other neurodiagnostic studies (e.g., CT scanning, MR imaging). The clinician presented with complaints of memory impairment or slowness in thinking in a patient who is depressed or paranoid may be unsure of the possible contribution of neurological changes to the clinical picture. Neuropsychological testing may be particularly helpful when the findings of the neurological examination and ancillary procedures are either negative or equivocal. The differential diagnosis of incipient dementia from depression is a case in point, particularly when computed tomography (CT) fails to yield definitive results.

3 Neuropsychological testing may be indicated in persons with epilepsy. Neuropsychological testing is used in these patients to monitor the efficacy and possible cognitive side effects of drug therapy (e.g., new anticonvulsant drug therapy) by comparing baseline performance with subsequent testing performance. Neuropsychological testing is also used to assess post-surgical changes in cognitive functioning to guide further treatment services. Preferably, these tests should be administered by a psychiatrist or certified psychologist trained to conceptualize the neuro-anatomical and the neuro-behavioral implications of the diagnostic entities under consideration and who is capable of interpreting patterns of test scores in view of principles of lateralization and localization of cerebral function. Codes 96105, 96111, 96116, 96118, 96119, 96120, 96125, and G0451 are defined by their CPT/HCPCS descriptors. Code represents the formal evaluation of aphasia using a psychometric instrument such as the Boston Diagnostic Aphasia Examination. This testing is typically performed once during treatment, and the medical necessity for such testing should be documented. Repeat testing should only be done if there is a significant change in the patient s aphasic condition. Codes 96118, 96119, 96120, describe testing which is intended to diagnose and characterize the neurocognitive effects of medical disorders that impinge directly or indirectly on the brain. Neuropsychological testing is considered medically necessary for the following indications: When there are deficits on standard mental status testing or clinical interview, and a neuropsychological assessment is needed to establish the presence of abnormalities or distinguish them from other disease processes; or When neuropsychological data could provide clarification of clinical, laboratory, and neuroimaging data to assist in establishing a clinical diagnosis in neurological or systemic conditions known to affect CNS functioning; or When there is a need to quantify cognitive or behavioral deficits related to CNS impairment, and the information will be useful in determining a prognosis or treatment planning by determining the rate of disease progression; or When there is a need for a pre-surgical or treatment-related cognitive evaluation to inform whether one might safely proceed with a medical or surgical procedure that may affect brain function (e.g., deep brain stimulation, resection of brain tumors or arteriovenous malformations, epilepsy surgery) or significantly alter a patient s functional status; or When there is a need to assess the potential impact of adverse effects of therapeutic substances that may cause cognitive impairment (e.g., radiation, chemotherapy, antiepileptic medications), and this information is utilized in treatment planning; or When there is a need to assess progression, recovery, and response to changing treatments, in patients with CNS disorders, in order to determine the most effective plan of care; or When there is a need for objective measurement of patients' subjective complaints about memory, attention, or other cognitive dysfunction, which directly impacts medical management by differentiating psychogenic from neurogenic syndromes (e.g., dementia vs. depression), and in some cases will result in initial detection of neurological disorders or systemic diseases affecting the brain; or When there is a need for treatment planning purposes of determining functional abilities/impairments in individuals with known or suspected CNS disorders (e.g., capacity for independent living or movement from a family home into an institutional setting); or When there is a need to determine whether a patient can comprehend and participate effectively in complex treatment regimens and to determine functional capacity for health care decision-making, independent living, etc.; or When there is a need to design, administer, and/or assess outcomes of cognitive rehabilitation procedures, often in collaboration with other specialists such as speech pathologists, occupational therapists, physiatrists, and rehabilitation psychologists; or When there is a need for treatment planning of identification and assessment of neurocognitive sequelae of disease ; or Assessment of neurocognitive functions for the formulation of rehabilitation and/or management strategies for certain individuals with neuropsychiatric disorders; or

4 When there is a need to diagnose cognitive or functional deficits in children and adolescents based on an inability to develop expected knowledge, skills or abilities as required to adapt to new or changing cognitive, social, emotional, or physical demands. The content of neuropsychological testing procedures (96118, 96119, 96120, 96125) differs from that of psychological testing ( and G0451) in that neuropsychological testing consists primarily of individually administered ability tests that comprehensively sample cognitive and performance domains that are known to be sensitive to the functional integrity of the brain (e.g., abstraction, memory and learning, attention, language, problem solving, sensorimotor functions, constructional praxis, etc.). Neuropsychological testing does not rely on self-report questionnaires such as the Minnesota Multiphasic Personality Inventory 2 (MMPI-2), rating scales such as the Hamilton Depression Rating Scale, or projective techniques such as the Rorschach or Thematic Apperception Test (TAT). In circumstances when additional time is necessary to integrate other sources of clinical data including previously completed and reported technician- and/or computer-administered tests, the neuropsychological testing may include time spent integrating self-report questionnaires. Psychological testing codes (96101, 96102, and 96103) include the administration, interpretation, and scoring of the tests mentioned in the CPT descriptors and other medically accepted tests for the evaluation of intellectual strengths, psychopathology, psychodynamics, mental health risks, insight, motivation, and other factors influencing treatment and prognosis. Psychological tests are used to address a variety of questions about people s functioning, diagnostic classification, co-morbidity, and choice of treatment approach. For example, personality tests and inventories evaluate the thoughts, emotions, attitudes, and behavioral traits that contribute to an individual s interpersonal functioning. The results of these tests determine an individual's personality strengths and weaknesses and may identify certain disturbances in personality or psychopathology. One type of personality test is the projective personality assessment, which asks a subject to interpret some ambiguous stimuli, such as a series of inkblots. The subject's responses can provide insight into his or her thought processes and personality traits. Examples of problems that might require psychological testing include: 1. Assessment of mental functioning for individuals with suspected or known mental disorders for purposes of differential diagnosis and/or treatment planning. 2. Assessment of patient strengths and disabilities for use in treatment planning or management when signs or symptoms of a mental disorder are present. 3. Assessment of patient capacity for decision-making when impairment is suspected that would affect patient care or management. 4. Assessment of mental function in certain chronic pain patients when indicated after psychological screening prior to surgical pain management intervention (e.g., implantable neurostimulator). 5. Assessment of mental function in a chronic pain patient with suspected somatization disorder. Changes in mental illness may require psychological testing to determine new diagnoses or the need for changes in therapeutic measures. Repeat testing not required for diagnosis or continued treatment would be considered medically unnecessary. Nonspecific behaviors that do not indicate the presence of, or change in, a mental illness would not be an acceptable indication for testing. Psychological or psychiatric evaluations that can be accomplished through the clinical interview alone (e.g., response to medication) would not require psychological testing, and such testing might be considered as medically unnecessary. Adjustment reactions or dysphoria associated with moving to a nursing facility do not constitute medical necessity for psychological testing. When a psychiatric condition or the presence of dementia has already been diagnosed, there is value to the testing only if the information derived from the testing would be expected to have significant impact on the understanding and treatment of the patient. Examples include a significant change in the patient s condition, the need to evaluate a patient s capacity to function in a given situation or environment, and/or the need to specifically tailor therapeutic and/or compensatory techniques to particular aspects of the patient s pattern of strengths and disabilities.

5 Limitations Psychological and Neuropsychological testing is not considered reasonable and necessary when: the patient is not neurologically and cognitively able to participate in a meaningful way in the testing process; administered for educational or vocational purposes that do not establish medical management; performed when abnormalities of brain or emotional function are not suspected; used for self-administered or self-scored inventories or screening tests of cognitive function (paper-and-pencil or computerized), e.g., AIMS, Folstein Mini-Mental Status Examination; Repeated when not required for medical decision-making. Examples of medical decision making include: whether to start or continue a particular rehabilitative or pharmacologic therapy); Administered when the patient has a substance abuse background, and any of the following apply: the patient has ongoing substance abuse such that test results would be inaccurate, or the patient is currently intoxicated; The patient has been diagnosed previously with brain dysfunction, e.g., Alzheimer s disease, and there is no expectation that the testing would impact the patient's medical management; The test is being given solely as a screening test for Alzheimer's disease. Medicare does not cover this screening for this diagnosis. Testing conducted when no mental illness/disability is suspected would be considered screening and would not be covered by Medicare. Non-specific behaviors that do not suggest the possibility of mental illness or disability are not an acceptable indication for testing. Evaluations of the mental status that can be performed within the psychiatric diagnostic evaluation (e.g., codes 90791, 90792), (e.g., a list of questions concerning symptoms of depression or organic brain syndrome, corresponding to brief questionnaires or screening measures such as the Folstein Mini Mental Status Examination or the Beck Depression Scale, or use of other mental status exams in isolation ) should not be classified separately as psychological or neuropsychological testing (codes , G0451) since they are typically part of a more general psychiatric/psychological clinical exam or interview. Psychological/neuropsychological testing to evaluate adjustment reactions or dysphoria associated with placement in a nursing home does not constitute medical necessity for testing. Testing of every patient upon entry to a nursing home would be considered a routine service and would not be covered by Medicare. However, some individuals enter a nursing home at a time of physical and cognitive decline and may require psychological/neuropsychological testing to arrive at a diagnosis and plan of care. Decisions to test individuals who have recently entered a nursing home need to be made judiciously, on a case-by-case basis. Each psychological/neuropsychological test administered must be individually medically necessary. A standard battery of tests is only medically necessary if each individual test in the battery is medically necessary. The psychological/neuropsychological testing codes should not be reported by the treating physician for only reading the testing report or explaining the results to the patient or family. Payment for these services is included in the payment for other services rendered to the patient, such as evaluation and management services. Psychological and neuropsychological testing codes should be reported by the performing provider (i.e., clinical psychologist, neuropsychologist, or physician) who administered the test. Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. 012x 013x 022x 023x Hospital Inpatient (Medicare Part B only) Hospital Outpatient Skilled Nursing - Inpatient (Medicare Part B only) Skilled Nursing - Outpatient

6 071x 075x 076x 077x 085x Clinic - Rural Health Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF) Clinic - Community Mental Health Center Clinic - Federally Qualified Health Center (FQHC) Critical Access Hospital Revenue Codes: Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes. Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes Behavioral Health Treatment/Services - Testing CPT/HCPCS Codes Group 1 Paragraph: N/A Group 1 Codes: PSYCHOLOGICAL TESTING (INCLUDES PSYCHODIAGNOSTIC ASSESSMENT OF EMOTIONALITY, INTELLECTUAL ABILITIES, PERSONALITY AND PSYCHOPATHOLOGY, EG, MMPI, RORSCHACH, WAIS), PER HOUR OF THE PSYCHOLOGIST S OR PHYSICIAN S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT PSYCHOLOGICAL TESTING (INCLUDES PSYCHODIAGNOSTIC ASSESSMENT OF EMOTIONALITY, INTELLECTUAL ABILITIES, PERSONALITY AND PSYCHOPATHOLOGY, EG, MMPI AND WAIS), WITH QUALIFIED HEALTH CARE PROFESSIONAL INTERPRETATION AND REPORT, ADMINISTERED BY TECHNICIAN, PER HOUR OF TECHNICIAN TIME, FACE-TO-FACE PSYCHOLOGICAL TESTING (INCLUDES PSYCHODIAGNOSTIC ASSESSMENT OF EMOTIONALITY, INTELLECTUAL ABILITIES, PERSONALITY AND PSYCHOPATHOLOGY, EG, MMPI), ADMINISTERED BY A COMPUTER, WITH QUALIFIED HEALTH CARE PROFESSIONAL INTERPRETATION AND REPORT ASSESSMENT OF APHASIA (INCLUDES ASSESSMENT OF EXPRESSIVE AND

7 RECEPTIVE SPEECH AND LANGUAGE FUNCTION, LANGUAGE COMPREHENSION, SPEECH PRODUCTION ABILITY, READING, SPELLING, WRITING, EG, BY BOSTON DIAGNOSTIC APHASIA EXAMINATION) WITH INTERPRETATION AND REPORT, PER HOUR DEVELOPMENTAL TESTING, (INCLUDES ASSESSMENT OF MOTOR, LANGUAGE, SOCIAL, ADAPTIVE, AND/OR COGNITIVE FUNCTIONING BY STANDARDIZED DEVELOPMENTAL INSTRUMENTS) WITH INTERPRETATION AND REPORT NEUROBEHAVIORAL STATUS EXAM (CLINICAL ASSESSMENT OF THINKING, REASONING AND JUDGMENT, EG, ACQUIRED KNOWLEDGE, ATTENTION, LANGUAGE, MEMORY, PLANNING AND PROBLEM SOLVING, AND VISUAL SPATIAL ABILITIES), PER HOUR OF THE PSYCHOLOGIST S OR PHYSICIAN S TIME, BOTH FACE-TO-FACE TIME WITH THE PATIENT AND TIME INTERPRETING TEST RESULTS AND PREPARING THE REPORT NEUROPSYCHOLOGICAL TESTING (EG, HALSTEAD-REITAN NEUROPSYCHOLOGICAL BATTERY, WECHSLER MEMORY SCALES AND WISCONSIN CARD SORTING TEST), PER HOUR OF THE PSYCHOLOGIST S OR PHYSICIAN S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT NEUROPSYCHOLOGICAL TESTING (EG, HALSTEAD-REITAN NEUROPSYCHOLOGICAL BATTERY, WECHSLER MEMORY SCALES AND WISCONSIN CARD SORTING TEST), WITH QUALIFIED HEALTH CARE PROFESSIONAL INTERPRETATION AND REPORT, ADMINISTERED BY TECHNICIAN, PER HOUR OF TECHNICIAN TIME, FACE-TO-FACE NEUROPSYCHOLOGICAL TESTING (EG, WISCONSIN CARD SORTING TEST), ADMINISTERED BY A COMPUTER, WITH QUALIFIED HEALTH CARE PROFESSIONAL INTERPRETATION AND REPORT STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG, ROSS INFORMATION PROCESSING ASSESSMENT) PER HOUR OF A QUALIFIED HEALTH CARE G0451 PROFESSIONAL S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT DEVELOPMENT TESTING, WITH INTERPRETATION AND REPORT, PER STANDARDIZED INSTRUMENT FORM

8 ICD-9 Codes that Support Medical Necessity Group 1 Paragraph: For CPT/HCPCS codes 96101, 96102, 96103, 96118, 96119, 96120, 96125, and G0451 only: Group 1 Codes: SENILE DEMENTIA UNCOMPLICATED - UNSPECIFIED PERVASIVE DEVELOPMENTAL DISORDER, RESIDUAL STATE ANXIETY STATE UNSPECIFIED - PSYCHIC FACTORS ASSOCIATED WITH DISEASES CLASSIFIED ELSEWHERE 317 MILD INTELLECTUAL DISABILITIES MODERATE INTELLECTUAL DISABILITIES - PROFOUND INTELLECTUAL DISABILITIES 319 UNSPECIFIED INTELLECTUAL DISABILITIES INSOMNIA DUE TO MENTAL DISORDER HYPERSOMNIA DUE TO MENTAL DISORDER REM SLEEP BEHAVIOR DISORDER - RECURRENT ISOLATED SLEEP PARALYSIS ALZHEIMER'S DISEASE PICK'S DISEASE OTHER FRONTOTEMPORAL DEMENTIA SENILE DEGENERATION OF BRAIN COMMUNICATING HYDROCEPHALUS OBSTRUCTIVE HYDROCEPHALUS IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS (INPH) CORTICOBASAL DEGENERATION CEREBRAL DEGENERATION IN DISEASES CLASSIFIED ELSEWHERE DEMENTIA WITH LEWY BODIES MILD COGNITIVE IMPAIRMENT, SO STATED OTHER CEREBRAL DEGENERATION SECONDARY PARKINSONISM ESSENTIAL AND OTHER SPECIFIED FORMS OF TREMOR ATHETOID CEREBRAL PALSY - ACUTE DYSTONIA DUE TO DRUGS OTHER ACQUIRED TORSION DYSTONIA

9 OROFACIAL DYSKINESIA SUBACUTE DYSKINESIA DUE TO DRUGS UNSPECIFIED EXTRAPYRAMIDAL DISEASE AND ABNORMAL MOVEMENT DISORDER NEUROLEPTIC MALIGNANT SYNDROME OTHER EXTRAPYRAMIDAL DISEASES AND ABNORMAL MOVEMENT DISORDERS ANOXIC BRAIN DAMAGE DEAF, NONSPEAKING, NOT ELSEWHERE CLASSIFIABLE 430 SUBARACHNOID HEMORRHAGE 431 INTRACEREBRAL HEMORRHAGE NONTRAUMATIC EXTRADURAL HEMORRHAGE SUBDURAL HEMORRHAGE UNSPECIFIED INTRACRANIAL HEMORRHAGE OCCLUSION AND STENOSIS OF BASILAR ARTERY WITH CEREBRAL INFARCTION - OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY WITH CEREBRAL INFARCTION CEREBRAL THROMBOSIS WITH CEREBRAL INFARCTION CEREBRAL EMBOLISM WITHOUT CEREBRAL INFARCTION CEREBRAL EMBOLISM WITH CEREBRAL INFARCTION CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITHOUT CEREBRAL INFARCTION CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITH CEREBRAL INFARCTION COGNITIVE DEFICITS APHASIA LATE EFFECTS OF CEREBROVASCULAR DISEASE, DYSARTHRIA ALTERATION OF CONSCIOUSNESS OTHER MEMORY LOSS EXCESSIVE CRYING OF CHILD, ADOLESCENT, OR ADULT ALTERED MENTAL STATUS APHASIA DYSARTHRIA OTHER SPEECH DISTURBANCE SYMBOLIC DYSFUNCTION UNSPECIFIED - ALEXIA AND DYSLEXIA OTHER SYMBOLIC DYSFUNCTION

10 ATTENTION OR CONCENTRATION DEFICIT COGNITIVE COMMUNICATION DEFICIT VISUOSPATIAL DEFICIT PSYCHOMOTOR DEFICIT FRONTAL LOBE AND EXECUTIVE FUNCTION DEFICIT OTHER SIGNS AND SYMPTOMS INVOLVING COGNITION CONCUSSION WITH NO LOSS OF CONSCIOUSNESS CONCUSSION WITH LOSS OF CONSCIOUSNESS OF 30 MINUTES OR LESS CONCUSSION WITH LOSS OF CONSCIOUSNESS FROM 31 TO 59 MINUTES CONCUSSION WITH MODERATE LOSS OF CONSCIOUSNESS CONCUSSION WITH PROLONGED LOSS OF CONSCIOUSNESS AND RETURN TO PRE- EXISTING CONSCIOUS LEVEL CONCUSSION WITH PROLONGED LOSS OF CONSCIOUSNESS WITHOUT RETURN TO PRE- EXISTING CONSCIOUS LEVEL CONCUSSION WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION CONCUSSION UNSPECIFIED CORTEX (CEREBRAL) CONTUSION WITHOUT OPEN INTRACRANIAL WOUND STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER AND UNSPECIFIED CEREBRAL LACERATION AND CONTUSION WITH OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED - EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITHOUT OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED - INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED LATE EFFECT OF INTRACRANIAL INJURY WITHOUT SKULL FRACTURE UNSPECIFIED ADVERSE EFFECT OF UNSPECIFIED DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE UNSPECIFIED CHILD ABUSE - SHAKEN BABY SYNDROME

11 OTHER CHILD ABUSE AND NEGLECT UNSPECIFIED ADULT MALTREATMENT - OTHER ADULT ABUSE AND NEGLECT ICD-9 Codes that DO NOT Support Medical Necessity N/A Associated Information Documentation Requirements The medical record must indicate testing is necessary as an aid in the diagnosis and therapeutic planning. The record must show the tests performed, scoring and interpretation, as well as the time involved for services that are time-based. The medical record should include all of the following information: Reason for referral. Tests administered, scoring/interpretation, and time involved. Present evaluation. Diagnosis (or suspected diagnosis that was the basis for the testing if no mental/neurocognitive illness was found). Recommendations for interventions, if necessary. Identity of person performing service. Utilization Guidelines Typically, psychological testing/neuropsychological testing may require four (4) to six (6) hours to perform (including administration, scoring, and interpretation.) If the testing is done over several days, the testing time should be combined and reported all on the last date of service. Supporting documentation in the medical record must be present to justify the medical necessity and hours tested per patient per evaluation. If the testing time exceeds eight (8) hours, medical necessity for the extended testing should be documented in the report. Use of such tests when mental or neurocognitive illness is not suspected would be a screening procedure not covered by Medicare. Each test performed must be medically necessary. Therefore, standardized batteries of tests are not acceptable unless each test in the battery is medically necessary. Routine re-evaluation of chronically disabled patients that is not required for a diagnosis or continued treatment is not medically necessary. Sources of Information and Basis for Decision American Academy of Clinical Neuropsychology (AACN), (October 2011) Neuropsychology Model LCD. Accessed at American Medical Association (2013) CPT Professional Edition CGS Administrators, LLC LCD (L31887) Code of Federal Regulations (CFR) Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions. HCPCS Level II 2013 Book, Professional Edition LCDs and policies from other Medicare contractors and private insurers

12 National Government Services, Inc. LCD (L26895) Novitas Solutions, Inc. LCD (L32766) Wisconsin Physicians Service Insurance Corporation LCD (L31990) Revision History Information Please note: The Revision History information included in this LCD prior to 1/24/2013 will now display with a Revision History Number of "R1" at the bottom of this table. All new Revision History information entries completed on or after 1/24/2013 will display as a row in the Revision History section of the LCD and numbering will begin with "R2". Revision History Date Revision History Number Revision History Explanation Reason(s) for Change 10/14/2013 R1 Revision Number: Original Publication: September 2013 Connection LCR A LCR B Associated Documents Attachments Comment summary 6/7/13-7/22/13 (a comment and response document) (PDF - 68 KB ) Coding Guidelines effec 10/14/13 (PDF - 92 KB ) Related Local Coverage Documents N/A Related National Coverage Documents N/A Public Version(s) Updated on 08/23/2013 with effective dates 10/14/ N/A Updated on 08/23/2013 with effective dates 10/14/ N/A Typographical Error Form Date: 08/05/2013 Page 1 of MP Part A/B LCD Comment Summary Sheet Psychological and Neuropsychological Tests: Medicare Part A/B local coverage determination (LCD) comment summary LCD Number L33688 Contractor Name First Coast Service Options, Inc. Contractor Numbers Florida Puerto Rico/U.S. Virgin Islands Florida Puerto Rico U.S. Virgin Islands Contractor Type MAC Part A/B LCD Title Psychological and Neuropsychological Tests AMA CPT Copyright Statement CPT only copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative

13 value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT ). Copyright American Dental Association. All rights reserved. CDT and CDT are trademarks of the American Dental Association. Start Date of Comment Period: 06/07/2013 End Date of Comment Period: 07/22/2013 Comments 1 through 11 address the considerable input to various sections of the LCD received from the Inter Organizational Practice Committee (IOPC), a coalition of representatives of various entities tasked with coordinating national neuropsychology advocacy efforts. Regarding the IOPC recommendations received, the contractor acknowledges that an extensive number of letters and s from various stakeholders across Florida were received in support of the IOPC s suggested changes to the policy. Comment #1: Neuropsychological and psychological testing are distinct evaluations that access very different clinical issues. The LCD intermixes these two types of evaluations in a confusing manner. The draft repeatedly refers to neuropsychological evaluations of individuals with psychiatric conditions and mental illness. However, neuropsychological tests provide measures of brain functioning to aid in the diagnosis, prognosis and treatment of medical disorders that impact central nervous system functioning. A suggestion was made to replace the original introduction to provide more clarity about neuropsychological and psychological assessment and the differences between the two. Contractor response: Thank you for your comments and suggestions. The final LCD will be revised to provide clarification between neuropsychological and psychological testing. Comment #2: For adjustment reactions or dysphoria associated with moving to a nursing facility do not constitute medical necessity for psychological testing, suggestion was made to add the following: unless a more serious mood disorder (e.g., major depression) is suspected upon admission to a nursing facility. In that case, psychological/neuropsychological testing may be indicated to develop appropriate treatment planning. Contractor response: The LCD already contains pertinent language addressing psychological/neuropsychological testing to arrive at a diagnosis and plan of care for individuals entering a nursing home. The Limitations section addresses the following: some individuals enter a nursing home at a time of physical and cognitive decline and may require psychological/neuropsychological testing to arrive at a diagnosis and plan of care. Decisions to test individuals who have recently entered a nursing home need to be made judiciously, on a case-by-case basis. Therefore no further changes will be made. Form Date: 08/05/2013 Page 2 of MP Part A/B LCD Comment Summary Sheet Comment #3: Revise language regarding neuropsychological testing does not rely on self-report measures Suggest changing to: Neuropsychological testing may include self-report questionnaires such as the Hamilton Depression Rating Scale, or projective techniques such as the Rorschach or Thematic Apperception Test (TAT), when questions of how brain damage or degenerative disease process may be affecting emotional expression (e.g., right hemisphere CVA) or how mood impairment might be affecting cognitive function (e.g., pseudodementia ) arise. Contractor response: The final LCD will provide clarification as follows: Neuropsychological testing does not rely on self-report questionnaires such as the Minnesota Multiphasic Personality Inventory 2 (MMPI-2), rating scales such as the Hamilton Depression Rating Scale, or projective techniques such as the Rorschach or Thematic Apperception Test (TAT). In circumstances when additional time is necessary to integrate other sources of clinical data including previously completed and reported technician- and/or computer-administered tests, the neuropsychological testing may include time spent integrating self-report questionnaires. Comment #4: Clarify language under Limitations section about reading the testing report and providing feedback to the patients and their families. To ensure stakeholders do not interpret this to mean that neuropsychologists should not use CPT code to provide direct feedback about the neuropsychological evaluation to patients. Contractor response: Thank you for your suggestion. The final LCD provides the following clarification: The psychological/neuropsychological testing codes should not be reported by the treating physician for only reading the testing report or explaining the results to the patient or family. Payment for these services is included in the payment for other services rendered to the patient, such as evaluation and management services. Psychological and neuropsychological testing codes should be reported by the performing provider (i.e., clinical psychologist, neuropsychologist, or physician) who administered the test. In addition, the Coding Guidelines provides clarification regarding feedback as follows: Information derived from psychological and neuropsychological testing is often provided to the patient and other individuals as authorized by the patient. This information includes the results of the evaluation, potential intervention options, and referrals. Time spent providing that feedback as well as receiving any response to that information provided by the patient and/or authorized individuals is coded, using the appropriate number of billing units, with the CPT code for the testing; code (for psychological testing) or code (for neuropsychological testing). However, only communication regarding the testing results and feedback would be coded in this manner; assessment and management of other aspects of the patient's care would be coded using

14 other appropriate CPT coding. (American Medical Association CPT Assistant (September 2010) Medicine: Health and Behavior Assessment/Intervention, 96101, (Q&A), page 9.) Comment #5: Concern was expressed there may be confusion with providers about the number of hours that exceeds greater than eight. Suggest the following change: Supporting documentation in the medical record must be present to justify greater than eight hours per patient per evaluation. If the testing is done over several days, the testing time should be combined and reported all on the last date of service. If the testing time exceeds eight hours, medical necessity for extended time should be documented in the report. Contractor response: Supporting documentation in the medical record must always be present to justify the medical necessity and hours tested per patient per evaluation. When the contractor states that typically psychological testing/neuropsychological testing may require four to six hours to perform (including administration, scoring, and interpretation), it s just indicating that this is the most common length of time for these tests. The contractor recognizes that tests could last up to eight hours and sometimes extended time is necessary. The emphasis intended is that for testing time exceeding eight hours, medical necessity for the extended testing should be documented in the report, since the provider could fall under medical review. Comment #6: The draft includes ICD-9 codes that support medical necessity. A suggestion was made to consider eliminating the diagnosis list. The Indications and Coverage section establish medical necessity more clearly than an ICD-9 code. The list of diagnosis codes limits the scope of diagnoses covered in situations where coverage is medically necessary. Other comments were received requesting to consider adding ICD-9 diagnosis codes within reason to reflect the indications for neuropsychological testing that may be used in persons with documented changes in cognitive function as it relates to neurological diseases, traumatic brain injuries, stroke, epilepsy, hydrocephalus, etc. Contractor response: Thank you for the comments. Additional diagnosis codes that describe the indications for neuropsychological testing will be added to the ICD-9 Codes that Support Medical Necessity section. Comment #7: Refer to the section titled ICD-9 Codes that Support Medical Necessity. Add the following: Any ICD- 9 code that is consistent with the indications of coverage is acceptable. Also, refer to the section titled ICD-9 Codes that DO NOT Support Medical Necessity. Add the following: Any ICD-9 code that is inconsistent with the indications of coverage is not acceptable. Contractor response: See contractor response to comment #6. Comment #8: Refer to the Limitations section that lists when testing is not considered reasonable and necessary. The third bullet states, Performed when abnormalities of brain function are not suspected. Suggestion was made to include or emotional function. Contractor response: The final revised LCD has incorporated this suggestion. Comment #9: Refer to the Limitations section that lists when testing is not considered reasonable and necessary: The fourth bullet states, used for self-administered or self-scored inventories, or screening tests of cognitive function Suggestion was made to remove self-administered or. Contractor response: The Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) Policy Manual, Chapter 11, states in part: In order to report a CNS assessment/test CPT code, the test cannot be self-administered. It must be administered by a physician, psychologist, technician, or computer as required by the code descriptor of the reported CPT code. As stated in the Coding Guidelines attachment to the policy, provisions of an LCD do not take precedence over NCCI edits. Form Date: 08/05/2013 Page 3 of MP Part A/B LCD Comment Summary Sheet Comment #10: Refer to the Documentation Requirements section, under the fourth bullet that states, Diagnosis (or suspected diagnosis that was the basis for the testing if no mental illness was found). Suggestion was made to add neurocognitive illness. Contractor response: The final revised LCD has incorporated this suggestion. Comment #11: Refer to the second paragraph under the Utilization Guidelines section, add or neurocognitive illness to the sentence, Use of such tests when mental illness is not suspected would be a screening procedure not covered by Medicare. Contractor response: The final revised LCD has incorporated this suggestion. Comment #12: Under the Indications of coverage and/or medical necessity sections that lists examples of problems that might require psychological testing, a: suggestion was made to keep all three examples but add the following two examples: Assessment of mental function in a patient recommend for an implantable pain control device and Assessment of mental function in a chronic pain patient with suspected somatization disorder. Contractor response: Thank you for your suggestion to add more examples to the list of problems that might require psychological testing. The final LCD will include examples related to chronic pain patients. These are only examples, and they do not represent an all-inclusive list. Comment #13: The paragraph beginning with Neuropsychological testing is a sub classification of can we add the Wisconsin Card Sorting Test or WCST to list of tests given as examples? This test is actually listed within the CPT descriptor.

15 Contractor response: Thank you for your comment. Reference to particular tests was removed from the text of the LCD since CPT codes already contain examples of tests. The final LCD was revised to provide more clarity about neuropsychological testing. Comment #14: Under Limitations, the fifth bullet point down should read Repeated when not required for medical decision-making. Examples of medical decision making include: whether to start or continue a particular rehabilitative program or pharmacologic therapy. Contractor response: Thank you for this suggestion. The final revised LCD has incorporated this suggestion for clarification. Comment #15: In the paragraph starting with the word Evaluations, the beginning of the first sentence should read Evaluations of the mental status that can be performed within the psychiatric clinical interview. In addition, the end of the last sentence in that same paragraph should read since they are typically part of a psychiatric clinical exam or interview. Contractor response: Thank you for the comments. The final revised LCD has incorporated these suggestions. Comment #16: Under the Limitations section, the first sentence of the last paragraph should read as follows: The psychological/neuropsychological testing codes should not be reported by the treating physician for only reading the testing report or explaining the results to the patient or family unless the treating physician administered the testing. Contractor response: Thank you for the comments. The final revised LCD added the statement that psychological and neuropsychological testing codes should be reported by the performing provider (i.e., clinical psychologist, neuropsychologist, or physician) who administered the test. Comment #17: Concern was expressed regarding the lack of reimbursement for provision of feedback regarding the results of the neuropsychological exam. Sometimes feedback can be provided by the referring sources (i.e., the physician). However, other times it is more appropriate for the neuropsychologist to provide this feedback, which typically occurs within a week of the assessment. Suggestion was made to consider reimbursement for this service, which often ends up being provided pro bono. Contractor response: See Contractor response to Comments # 4. Psychological and Neuropsychological Tests Form Date: 04/29/13 Page 1 of MP Part AB FL Draft LCD FIRST COAST SERVICE OPTIONS MAC - PART A/B CODING GUIDELINES LCD Database ID Number L33688 Contractor Name First Coast Service Options, Inc. Contractor Number Florida PR/USVI Florida Puerto Rico Virgin Islands LCD Title Psychological and Neuropsychological Tests Coding Guidelines CMS Manual System, Pub , Medicare Benefit Policy Manual, Chapter 15, Section Psychological Tests and Neuropsychological Tests: Payment for psychological testing is limited to physicians, clinical psychologists, and on a limited basis, to qualified non-physician practitioners (e.g., speech language pathologists for aphasia evaluation). Independently Practicing Psychologists (IPPs) may bill for psychological and/or neuropsychological tests when the tests are ordered by a physician. Psychological and neuropsychological tests performed by a psychologist (who is not a CP) practicing independently of an institution, agency, or physician s office are covered when a physician orders such tests. An IPP is any psychologist who is licensed or certified to practice psychology in the State or jurisdiction where furnishing services or, if the jurisdiction does not issue licenses, if provided by any practicing psychologist. (It is CMS s understanding that all States, the District of Columbia, and Puerto Rico license psychologists, but that some trust territories do not. Examples of psychologists, other than CPs, whose psychological and neuropsychological tests are covered under the diagnostic tests provision include, but are not limited to, educational psychologists and counseling psychologists.)

16 Medicare does not authorize payment for psychological and neuropsychological testing when performed on an incident to basis. Information derived from psychological and neuropsychological testing is often provided to the patient and other individuals as authorized by the patient. This information includes the results of the evaluation, potential intervention options, and referrals. Time spent providing that feedback as well as receiving any response to that information provided by the patient and/or authorized individuals is coded, using the appropriate number of billing units, with the CPT code for the testing; code (for psychological testing) or code (for neuropsychological testing). However, only communication regarding the testing results and feedback would be coded in this manner; assessment and management of other aspects of the patient's care would be coded using other appropriate CPT coding. Psychological and Neuropsychological Tests Form Date: 04/29/13 Page 2 of MP Part AB FL Draft LCD Refer to the National Correct Coding Initiative (NCCI) Policy Manual for correct coding guidelines and applicable code combinations prior to billing Medicare. Provisions of an LCD do not take precedence over NCCI edits. *** Physicians must report services correctly. The NCCI Policy Manual for Medicare Service discusses general coding principles and principles more relevant to specific groups of HCPCS/CPT codes. Although the emphasis in the manual is correct coding, there are certain types of improper coding that physicians must avoid. Procedures should be reported with the most comprehensive CPT code that describes the services performed. Physicians must not unbundle the services described by a HCPCS/CPT code. Physicians must avoid upcoding or downcoding and must report units of service correctly. Central Nervous System Assessments/Tests (NCCI Manual, Chapter 11): 1. Neurobehavioral status exam (CPT code 96116) should not be reported when a mini-mental status examination is performed. CPT code should never be reported with psychiatric diagnostic examinations (CPT codes or 90792). CPT code may be reported with other psychiatric services or evaluation and management services only if a complete neurobehavioral status exam is performed. If a mini-mental status examination is performed by a physician, it is included in the evaluation and management service. 2. CPT codes describe psychological testing differing by method of performance and interpretation. Two or more codes from this code range may be reported on the same date of service if and only if the differing testing techniques are utilized for different psychological tests. Similarly, CPT codes describe neuropsychological testing differing by method of performance and interpretation. Two or more codes from this latter code range may be reported on the same date of service if and only if the differing testing techniques are utilized for different neuropsychological tests. 3. The psychiatric diagnostic interview examination (CPT codes 90791, 90792) and psychological/ neuropsychological testing (CPT codes 96101, 96118) must be distinct services. CPT Manual instructions permit physicians to integrate other sources of clinical data into the report that is generated for CPT codes or Since the procedures described by CPT codes and are timed procedures, physicians should be careful to avoid reporting time for duplicating information included in the psychiatric diagnostic interview examination and report. 4. A physician may report CPT codes (psychological testing...) or (neuropsychological testing...) only if the physician personally administers at least one test to the patient. 5. Central nervous system (CNS) assessment/test CPT codes (e.g., , ) should not be reported for tests that are reportable as part of an evaluation and management service when performed. In order to report a CNS assessment/test CPT code, the test cannot be self-administered. It must be administered by a physician, psychologist, technician, or computer as required by the code descriptor of the reported CPT code. The test must assess CNS function (e.g., psychological health, aphasia, neuropsychological health) per requirements of the CNS assessment/test CPT code descriptors. The assessment must utilize tests described by the code descriptor or other tests not available in the public domain. Comments N/A Revision Revision History Date 10/14/2013 Original