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Behavioral Heath Treatment/Services - Documentation Requirements

By:  Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Published:  February 12th, 2016

According to Noridian's LCD, Psychological and Neuropsychological Tests (L34520), 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 and not covered. 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.

When using the following CPT/HCPCS codes 961019610296103,  96116961189611996120,and G0451: for Behavioral Health Treatment/Services see list for ICD-10-CM codes that support medical necessity.


References:

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Behavioral Health Resources

  • Reimbursement Guide
  • ICD-10-CM Specialty Specific Code Book
  • Provider Documentation Guides
  • Cheat Sheets and Quick Coding Cards
  • ICD-10-CM Comprehensive Code Books
  • and more...


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