Setting the stage
Administering the Linus Health digital cognitive assessments in the primary care setting enables early detection, empowers providers with actionable clinical insights, and supports patients with personalized action plans. These digital cognitive assessments signify the right care, in the right place, at the right time, which is an important step towards streamlining testing for signs of Alzheimer’s disease and other dementias and alleviating wait times of a bottlenecked neurology clinical pathway with more appropriate referrals.
Like many things that matter, neuropsychological testing takes time. We know that reimbursement is important to you, and we are committed to your practice’s successful reimbursement for time spent administering and evaluating the Linus Health CCE and other cognitive assessments.
An important first step in billing for the Linus Health CCE is understanding the three common CPT codes that can be used for neuropsychological testing. It is extremely important to note that Medicare and other payers will not pay for cognitive screening but will pay for cognitive testing. Exact reimbursement amounts for each CPT code will depend on your geographic region and the patients’ specific health insurance or Medicare plans.
Medical necessity
Medical necessity is a key part of billing these neuropsychological testing CPT codes. Medicare Part B generally covers outpatient care and services when they’re medically necessary. According to the Centers for Medicare & Medicaid Services (CMS), medically necessary services are services or supplies that are needed to diagnose or treat a medical condition and that meet accepted standards of medical practice. To successfully bill and be reimbursed for neuropsychological testing under traditional Medicare, a provider must first establish medical necessity, which is reflected by the assignment of an appropriate diagnosis code when billing these services.
The exact definition of medical necessity varies by region, but in general, cognitive testing can be used in developing treatment plans or managing disorders for patients with signs and symptoms of mental illness or neurological disease. When a psychiatric condition or dementia is already diagnosed, cognitive testing is valuable when it significantly impacts the understanding and treatment of the patient.
Because Medicare uses regional administrative contractors or MACs, there will be some differences in medically necessary diagnosis codes based on geographic location, although some are used by all MACs (i.e. generalized anxiety disorder, primary insomnia, and attention deficit hyperactivity disorder). Medicare provides over 2,000 qualified medically necessary diagnosis codes, and it is very important to always check the policies, medical necessity articles, and local coverage determinations of your local MAC. Please note that commercial payers may also have their own policies in regards to neuropsychological testing.
CPT codes
There are three main CPT codes used for the administration and evaluation of neurocognitive assessments. CPT code 96138 is used when the assessment was administered by a clinically trained technician, such as a registered nurse or medical assistant, while CPT code 96136 can be used if the assessment was administered by a physician, nurse practitioner, or physician’s assistant. These codes are time-based codes, and the administrator must spend a minimum of 16 minutes of face-to-face time with the patient, including rooming the patient, preparing the iPad, instructing the patient, and the actual completion of the assessment.
To meet the requirements of these CPT codes, the testing session must consist of two or more relevant assessments. The Linus Health CCE consists of an immediate and delayed recall task as well as a clock drawing section, which fulfills this testing requirement. Performing two or more separate Linus Health assessments would also meet this requirement. The 2024 non-facility Medicare reimbursement rates for these CPT codes are shown below.
CPT code 96132 can be used for test evaluation and must be provided by a physician, nurse practitioner, or physician’s assistant. This code is also time-based and requires a minimum of 31 minutes to be spent between face-to-face and non-face-to-face time. This could include integrating patient data into the chart, interpreting test results, clinical decision-making, and discussing results with the patient. The 2024 non-facility Medicare reimbursement rate for CPT code 96132 is shown below.
Documentation requirements for CPT code 96132 include:
- Documentation of the diagnosis supporting medical necessity
- Provider assessment of patient complaint
- Relevant medical history
- Results of pertinent tests and procedures
- Test administered
- Time involved
- Identity of the person performing the services
- Treatment plan, prognosis, and progress
- Physician or non-physician signature responsible for providing care
Linus Health and your practice workflow
Linus Health digital cognitive assessments can be completed in conjunction with the Medicare Annual Wellness Visit (AWV). If cognitive concern is reported or observed during the AWV, then a cognitive assessment can be completed, documented, and billed, making sure to link the medically necessary diagnosis code(s) for cognitive concern to the administration and evaluation CPT codes. Linus assessments should only be performed in conjunction with the Medicare AWV if enough time has been allotted in the provider/practice’s schedule. Whether or not the administration and the evaluation are done during the same encounter or separate encounters depends upon your clinical workflow and schedule.
Likewise, if cognitive concern is reported or observed during an evaluation and management visit for a separate concern, an appropriate cognitive assessment can be completed, documented, and billed with the corresponding medical necessity diagnosis code for the cognitive concern(s). The practice must keep in mind that time cannot be shared or overlapped in order to meet individual code requirements, and all times should be documented per individual code requirements.
Modifiers
When billing neuropsychological administration and evaluation with an E/M visit, payers typically require appending modifier -25 for significant, separately identifiable E/M and modifier -59 onto each neuropsychological testing code for distinct procedural service when billing unrelated E/M and neuropsychological testing codes together. Modifiers are two character codes appended to a CPT or HCPCS Level 2 code that provide additional information about the medical procedure, service, or supply involved without changing the meaning of the code. They communicate a certain circumstance regarding the performance of a procedure or service to the payer. By appropriately utilizing modifiers -25 and -59, the procedures should remain unbundled and should be paid separately.
Patient responsibility
Patients will usually have a small financial responsibility for Linus Health CCE test administration and evaluation. The 2024 Medicare Part B annual deductible is $240. After the patient meets the annual deductible, Medicare Part B pays 80% of the reasonable charge for a covered service. The patient is then responsible for the remaining 20%, known as coinsurance. For Medicare Advantage and other commercial plans, patient responsibility varies by plan, as patients could have a deductible, coinsurance, or a copay. The Linus Health neuropsychological administration and evaluation codes are covered services, and practices should be sure to set expectations with their patients that there will most likely be patient responsibility for neuropsychological testing.
Check with all payers to confirm CPT code coverage, medical necessity guidelines, and prior authorization requirements for neuropsychological testing prior to test administration.
Successful reimbursement
Now that we have provided basic information about billing CPT codes and ICD-10 codes for neuropsychological testing, let’s talk about some tips to help ensure successful reimbursement.
- Be sure that there is sufficient time in your schedule to utilize these codes.
- Always link valid diagnoses of medical necessity to neuropsychological testing codes.
- Effectively and proactively communicate patient coinsurance responsibility to your patients to minimize friction.
Stay tuned for our next blog post, where we’ll discuss the value of Linus Health within the scope of the Quadruple Aim of Healthcare.