by Find-A-Code™
Jan 1st, 2019 - Reviewed/Updated May 4th
Developmental screening/testing uses standardized tools to identify or rule-out developmental delays such as cognitive, motor, language, and social skills. When testing is completed, a report is compiled showing the interpretation and results of the administered tests. The report may include recommendations for further evaluation, intervention, and/or support services.
Documentation should include ALL of the following:
Time involved, preferably with start and stop times, including time for interpretation and report Note: When services span more than one day, documentation should clearly indicate the time spent on each day. However, payers may have different requirements for the reporting of dates when submitting a claim. Be aware of these differences. Tests administered and scored Interpretation of findings and written report Present evaluation Diagnosis (if no mental/neurocognitive disorder/condition was found during the screen, report the diagnosis that was the basis for the testing) Recommendations for interventions, if necessary Name and credentials of provider performing the service Referral – if these services are being requested by another healthcare professional, include the reason for the referral and the name of the referring provider
Performed by:
- To the extent authorized under state scope of practice.
- MD/DO - Physician (MD/DO (Doctor of Osteopathic Medicine)
- CP - Clinical Psychologist (CP)
- NP - Nurse Practitioner (NP)
- CNS - Clinical Nurse Specialist (CNS)
- PA - Physician Assistant (PA)
- IPP - Independently Practicing Psychologist (IPP)
- Always verify your state scope of practice to ensure coverage. Students/trainees performing tests are typically NOT covered
The following Medicare Guidelines provide additional information:
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“Psychological and neuropsychological tests performed by a psychologist (who is not a CP) practicing independently of an institution, agency, or physician’s office are covered when a physician orders such tests. An IPP is any psychologist who is licensed or certified to practice psychology in the State or jurisdiction where furnishing services or, if the jurisdiction does not issue licenses, if provided by any practicing psychologist. (It is CMS’ understanding that all States, the District of Columbia, and Puerto Rico license psychologists, but that some trust territories do not. Examples of psychologists, other than CPs, whose psychological and neuropsychological tests are covered under the diagnostic tests provision include, but are not limited to, educational psychologists and counseling psychologists.)”
– Source: Medicare Benefit Policy Manual Chapter 15 (Rev. 13629; Issued: 02-12-25),
Section 80.2 - Psychological Tests and Neuropsychological Tests |
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