2025 CPT code 96130
Effective Date: N/A Medicine - Psychology Feed
Psychological testing evaluation services, including integration of patient data, interpretation of test results and clinical data, clinical decision making, treatment planning, reporting, and interactive feedback; first hour.
Modifiers may be applicable. For example, modifier 25 can be used to indicate that this service is separate and distinct from an evaluation and management (E/M) service provided on the same day. Modifier 59 may be used when billing with an Evaluation and Management code and 96130, and the E&M code should be billed first with modifier 25. Modifier XE signifies distinct encounters for assessment/reassessment and testing on the same day. Modifier U7 is applicable in specific circumstances, such as services rendered during a practicum under supervision, as defined by applicable state administrative code.
Medical necessity must be established by documenting the clinical rationale for the evaluation, connecting it to the patient's presenting symptoms, functional impairments, or suspected condition.
The clinician explains the testing process, administers standardized psychological tests (written, oral, or computerized), interprets the results, integrates patient data, formulates a diagnosis and treatment plan, prepares a report, and provides feedback to the patient and/or family.
In simple words: The healthcare provider conducts an evaluation using psychological tests, interprets the results, develops a treatment plan, and discusses these with you and/or your family. This code covers the first hour of this process.
This code represents the first hour of psychological testing evaluation services performed by a physician or other qualified healthcare professional. It includes integrating patient data, interpreting standardized test results and clinical data, making clinical decisions, planning treatment, generating a report, and providing interactive feedback to the patient, family member(s), or caregiver(s). The total time spent for this code includes face-to-face time with the patient and time spent preparing visit.
Example 1: A physician evaluates a patient with suspected ADHD. They administer standardized tests, interpret the results, integrate the findings with the patient's history, and develop a treatment plan, discussing it with the patient and parents. This process takes one hour., A psychiatrist evaluates a patient experiencing anxiety. They administer several tests, interpret the results, create a comprehensive report, and discuss treatment options and next steps with the patient. The entire evaluation and discussion take 45 minutes., A qualified healthcare professional assesses a patient for cognitive decline. They administer a series of cognitive tests, interpret the findings, formulate a diagnosis, and develop a treatment plan which they discuss with the patient and their caregiver. The session lasts 1 hour and 15 minutes, requiring an additional add-on code (96131) for the additional time.
Documentation must include the total time spent on the evaluation, including face-to-face interaction and result interpretation, specific test(s) administered, a summary of the findings, the diagnosis, the treatment plan, and any interactive feedback provided to the patient or family.
** It's important to distinguish 96130 (evaluation services) from codes for test administration and scoring (96136, 96137, 96138, 96139). Time spent on interactive feedback to the patient/family is included in 96130. Ensure proper documentation justifies medical necessity and time spent. This code represents the first hour. Use 96131 for each additional hour. Reimbursement rates vary based on factors like location, payer, and individual contracts.
- Specialties:Psychiatry, Psychology, Neurology, and other specialties requiring psychological evaluations.
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Psychiatric Facility-Partial Hospitalization, Community Mental Health Center, and other applicable places of service.