2025 CPT code 96138
(Active) Effective Date: N/A Revision Date: N/A Neuropsychological Testing - Central Nervous System Assessments/Tests Medicine Services and Procedures Feed
Technician-administered psychological or neuropsychological test administration and scoring; two or more tests, any method; first 30 minutes.
Modifier 59 (Distinct procedural service) may be appended if 96138 is billed with other services on the same day to indicate that the service is distinct from those other procedures. Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day) may be used when billed with an EM service.
Medical necessity for psychological or neuropsychological testing must be established based on the patient's clinical presentation, medical history, and the need to assess cognitive functioning in the context of a specific condition or concern. Appropriate medical documentation is required to support the medical necessity.
The technician's role involves explaining the tests to the patient, administering the tests, and scoring them. The technician does not interpret the results. Interpretation is the responsibility of a qualified healthcare professional.
In simple words: A technician gives and grades two or more psychological or brain-related tests. This code covers the first 30 minutes of testing; additional time needs a separate code.
This CPT code encompasses the administration and scoring of two or more psychological or neuropsychological tests by a technician.The tests can be administered using any method (paper, verbal, electronic).The code covers the first 30 minutes of this service.A minimum of 16 minutes of face-to-face time must be spent to qualify for billing this code.Additional 30-minute intervals beyond the initial 30 minutes are billed using CPT code 96139.
Example 1: A technician administers the Wechsler Adult Intelligence Scale (WAIS), the Bender-Gestalt test, and a personality inventory to a patient. The total time spent administering and scoring the tests is 45 minutes.Code 96138 is billed for the first 30 minutes, and code 96139 is billed for the additional 15 minutes., A technician administers a battery of neuropsychological tests, including the Trail Making Test, the Stroop Test, and the Wisconsin Card Sorting Test to a patient. The total time spent administering and scoring the tests is 60 minutes. Code 96138 is billed once for the first 30 minutes and code 96139 is billed twice for the additional 30 minutes., A technician administers a brief cognitive screening tool, the Montreal Cognitive Assessment (MoCA) to several patients in a busy clinic setting. The time spent with each patient varies, but in one case, it takes 25 minutes to administer and score the test. Because the minimum time requirement of 16 minutes for 96138 is met, 96138 can be billed for that single administration.
Documentation should include the type and number of tests administered, the method of administration (paper, computer, etc.), the total time spent on administration and scoring, and confirmation that the tests were administered by a technician.The documentation should also contain a record of the patient's performance on each test.
** This code is specifically for technician-administered testing.If the testing is performed by a physician or other qualified healthcare professional, use CPT code 96136 instead.Always consult the most current CPT manual for the latest updates and guidelines.
- Revenue Code: Z2 (Undefined Codes)
- RVU: This information is not available in the provided sources.RVUs vary based on location and payer.
- Global Days: Not applicable.
- Payment Status: Active
- Modifier TC rule: Not applicable
- Fee Schedule: Historical fee schedule data is not available in provided sources. Consult your local payer.
- Specialties:Neuropsychology, Psychology, Psychiatry, Neurology, Family Medicine, Internal Medicine, Pediatrics
- Place of Service:Office, Hospital (Inpatient or Outpatient), Clinic, Other