2025 CPT code 96131
Psychological testing evaluation services by a physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback, each additional hour (List separately in addition to code for primary procedure).
Modifiers may be applicable in certain circumstances. For example, modifier -52 may be used to indicate reduced services.
Medical necessity must be established for psychological testing. The documentation should support the need for testing based on the patient's symptoms, history, and clinical presentation.
The physician or qualified healthcare professional is responsible for selecting and administering the tests, integrating patient data, interpreting results, making clinical decisions, formulating a treatment plan, generating a report, and providing feedback to the patient and/or their family.
In simple words: This code covers the additional time a healthcare professional spends reviewing and explaining the results of psychological tests, creating a treatment plan, and discussing it with the patient and their family.
This code represents the additional hours spent by a physician or other qualified healthcare professional evaluating and interpreting psychological tests.It includes integrating patient data, interpreting standardized test results and clinical data, making clinical decisions, planning treatment, preparing a report, and providing interactive feedback to the patient, family, or caregivers.This code is used for each additional hour beyond the first hour of evaluation, which is billed under code 96130.
Example 1: A patient with suspected ADHD undergoes psychological testing. The initial evaluation and interpretation take one hour (96130). An additional hour is spent integrating information from other sources and discussing the results with the patient and parents (96131)., A patient with a traumatic brain injury requires neuropsychological testing. The initial evaluation takes one hour (96132). Due to the complexity of the case, an additional hour is needed to interpret the test results and formulate a comprehensive rehabilitation plan (96133)., A patient is evaluated for depression and anxiety. The initial psychological evaluation lasts one hour (96130), and an additional 30 minutes is required to fully interpret the results, integrate patient history, and finalize the report (96131).
Documentation should include the following: reason for testing, patient history, specific tests administered, test results, interpretation of findings, diagnosis, treatment plan, and documentation of interactive feedback provided to the patient/family.
- Specialties:Clinical Psychology, Neuropsychology, Psychiatry, and other specialties that utilize psychological testing.
- Place of Service:Office, Outpatient Hospital, Inpatient Hospital, and other settings where psychological testing is performed.