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Date Printed: October 17, 2017: 04:29 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-95805-14

Original Effective Date: 09/15/01

Reviewed: 10/25/12

Revised: 05/11/14

Subject: Neuropsychological Testing

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions
Other References Updates

DESCRIPTION:

Neuropsychology is a sub-specialty of psychology and is the study of brain-behavior relationships in individuals with cognitive dysfunction due to injury, disease, or abnormal development of the brain. The goal of clinical neuropsychology is to reveal the effects of brain damage on behavior, and to be able to account for the influences of other factors such as genetic, developmental, emotional and observed contributions on cognitive functioning.

The neuropsychological examination has three general aims:

There are many neuropsychological testing batteries. Combinations of evaluation instruments are often utilized to devise a “battery”. Two of the most commonly used are the Halstead-Reitan Battery and the Luria-Nebraska Neuropsychological Battery. The Halstead-Reitan Battery is a collection of tests that are found to be adequate in discriminating brain-damaged individuals from neurologically healthy individuals. The Luria-Nebraska Neuropsychological Battery uses 269 selected test items composed of 11 clinical/ability scales measuring motor abilities, rhythm sense and reproduction, tactile abilities, visual abilities, receptive speech, expressive speech, writing, reading, arithmetic abilities, memory function, and intelligence. Three additional scales provide information regarding the presence of pathognomonic signs, left hemisphere damage, and right hemisphere damage.

Neuropsychological assessments are typically performed by licensed clinical neuropsychologists, but may also be performed by neurologists, psychiatrists, and psychologists. Neuropsychological testing may be considered a medical or psychiatric service depending on the patient diagnosis.

POSITION STATEMENT:

Neuropsychological meets the definition of medical necessity when performed for the evaluation of individuals with cognitive dysfunction due to injury, disease, or abnormal development of the brain.

Examples of indications for neuropsychological testing include:

Neuropsychological testing is not covered when performed for the following:

Neuropsychological testing is considered not medically necessary for uncomplicated cases of attention deficit disorder with or without hyperactivity (ADD / ADHD). ADD / ADHD is considered complicated when there is strong evidence of a possible underlying neurological disorder. Neuropsychological testing may be considered medically necessary for neurologically complicated cases of ADHD (e.g., post head trauma, seizures).

BILLING/CODING INFORMATION:

The following codes may be used to describe neuropsychological testing:

CPT Coding:

96116

Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, e.g., acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist’s or physician’s time, both the face-to-face time with the patient and time interpreting test results and preparing the report

96118

Neuropsychological testing (e.g., Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), per hour of the psychologist’s or physician’s time, both face-to-face time administering tests to the patient and time interpreting test results and preparing the report

96119

Neuropsychological testing (e.g., Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face

96120

Neuropsychological testing (e.g., Wisconsin Card Sorting Test), administered by a computer, with qualified health care professional interpretation and report

NOTE: Per CPT 96118 is used in those circumstances when additional time is necessary to integrate sources of clinical data, including previously completed and reported technician-and computer administered tests.

CPT 96118 is not reported for the interpretation of 96119 or 96120.

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Therapy and Rehabilitation Services (L29289) located at fcso.com.

DEFINITIONS:

Cognitive: of, relating to, or being conscious; intellectual activity (as thinking, reasoning, remembering, imagining, or learning words).

Cognitive therapy: psychotherapy that emphasizes the substitution of desirable patterns of thinking for undesirable ones (e.g., for depression).

Neurocognitive: of relating to, or involving the central nervous system and cognitive abilities.

Neurogenic: originating in nervous tissue; induced, controlled, or modified by nervous factors; disordered because of abnormally altered neural relations.

Pathognomonic: distinctively characteristic of a particular disease or condition (i.e., when the patient's attitudes are pathognomonic of one of the classical psychoneuroses).

Psychogenic: originating in the mind or in mental or emotional conflict.

OTHER:

None applicable.

REFERENCES:

  1. Agency for Healthcare Research and Quality (AHRQ). National Guideline Clearinghouse: Guideline Summary NGC-2048. Practice parameter: screening and diagnosis of autism. Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Child Neurology Society. August 2000.
  2. Agency for Healthcare Research and Quality (AHRQ). National Guideline Clearinghouse: Guideline Summary NGC-6933. Recommendations for the diagnosis and management of Alzheimer's disease and other disorders associated with dementia: EFNS guideline. European Federation of Neurological Societies. January 2007.
  3. Agency for Healthcare Research and Quality (AHRQ). National Guideline Clearinghouse: Guideline Summary NGC-7193. Attention deficit hyperactivity disorder. Diagnosis and management of ADHD in children, young people and adults. National Institute for Health and Clinical Excellence (NICE). September 2008.
  4. Agency for Healthcare Research and Quality (AHRQ). National Guideline Clearinghouse: Guideline Summary NGC-8514. Head (trauma, headaches, etc., not including stress & mental disorders). Work Loss Data Institute. 2011.
  5. Agency for Healthcare Research and Quality (AHRQ). National Guideline Clearinghouse: Guideline Summary NGC-8985. The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care. National Institute for Health and Clinical Excellence (NICE). January 2012.
  6. American Academy of Child and Adolescent Psychiatry (1997), Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 36(10suppl).
  7. American Academy of Child and Adolescent Psychiatry: Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/Hyperactivity Disorder. J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 46:7, JULY 2007.
  8. American Academy of Neurology Practice parameter: Evaluation of the child with global developmental delay: Report of the Quality Standards Subcommittee of the American Academy of Neurology and The Practice Committee of the Child Neurology Society. Neurology 2003;60;367.
  9. American Academy of Neurology. Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Assessment: Neuropsychological Testing of Adults. Considerations for Neurologists. Neurology. 1996; 47:592-599.
  10. American Psychiatric Association. Practice guideline for the Psychiatric Evaluation of Adults. Second Edition. May 2006. Accessed on November 11, 2009.
  11. American Medical Association CPT (current edition)
  12. Filipek PA et al. Practice parameter: screening and diagnosis of autism: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Child Neurology Society. Neurology 2000 Aug 22;55(4):468-79.
  13. Florida Medicare Part B Medical Policy # 95800 – Neurodiagnostic Services (11/96)
  14. Florida Medicare Part B Medical Policy # 96100 – Psychological Testing (02/24/97)
  15. Florida Medicare Part B Local Coverage Determination. LCD for Therapy and Rehabilitation Services (L29289). Revised 03/01/10. Accessed 10/08/12.
  16. HAYES Medical Technology Directory; Neuropsychological Assessment for Dementia (07/31/97; updated 02/24/03)
  17. HAYES Medical Technology Directory; Neuropsychological Assessment for Traumatic Brain Injury (07/31/97; updated 02/24/03)
  18. HAYES Medical Technology Directory; Neuropsychological Assessment for Infectious Disease Sequelae (11/28/97; updated 02/24/03)
  19. Lindsay MP, Gubitz G, Bayley M, Hill MD, Davies-Schinkel C, Singh S, and Phillips S. Canadian Best Practice Recommendations for Stroke Care (Update 2010). On behalf of the Canadian Stroke Strategy Best Practices and Standards Writing Group. 2010; Ottawa, Ontario Canada: Canadian Stroke Network.
  20. Medicare Carriers Manual (MCM 2070, 2070.2)
  21. National Collaborating Centre for Mental Health. Attention deficit hyperactivity disorder. Diagnosis and management of ADHD in children, young people and adults. London (UK): National Institute for Health and Clinical Excellence (NICE); 2008 Sep. 59 p. (Clinical guideline; no. 72).
  22. Rizzutti S, Sinnes EG, Scaramuzza LF, Freitas L, Pinheiro D, Palma SM, Mello CB, Miranda MC, Bueno OF, Muszkat M. Clinical and neuropsychological profile in a sample of children with attention deficit hyperactivity disorders. Arq Neuropsiquiatr. 2008 Dec;66(4):821-7.
  23. Seidman, Larry J: Tasman: Psychiatry, 1st ed. WB Saunders Company, 1997
  24. Stebbins, Glenn T: Goetz: Textbook of Clinical Neurology, 1st ed. WB Saunders Company, 1999
  25. St. Anthony’s ICD-9-CM Code Book (current edition)
  26. Waldemar G et al. Recommendations for the diagnosis and management of Alzheimer's disease and other disorders associated with dementia: EFNS guideline. Eur J Neurol 2007 Jan;14(1):e1-26.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 10/25/12.

GUIDELINE UPDATE INFORMATION:

09/15/01

Medical Coverage Guideline Reformatted and Revised.

09/15/03

Reviewed; no changes in coverage.

01/01/06

HCPCS coding update consisting of the deletion of 96117 and the addition of 96118, 96119 and 96120.

05/15/07

Medical Policy Archived (No longer Active).

01/15/10

Guideline revised and reformatted. Returned to active status.

11/15/12

Revision; added a coverage statement for neurologically complicated Attention Deficit Disorder with or without hyperactivity (ADD/ADHD); updated references and reformatted guideline.

05/11/14

Revision: Program Exceptions section updated.

Date Printed: October 17, 2017: 04:29 PM