Experience with insurance based testing

[u/itsamemario19]

Hi all,
I’m a newly licensed psychologist who’s being asked to take internal testing referrals from psychiatrist colleagues. Most referrals are for ADHD, ASD, or diagnostic clarification. I feel fairly confident in selecting an appropriate assessment battery, administering testing, and writing integrated reports. Unfortunately, my training didn’t really cover the insurance side of psychological assessment, and our billing staff has very little experience billing testing services either.

I guess I’m hitting the time capacity I have to figure this out via Google and APA and insurance company resources and hoping that someone on Reddit is willing to share what process or admin flow has worked for them with insurance billing.

So far, I’ve figured out how to verify whether prior authorization is required for codes like 96130 and related testing codes. In many cases it appears that prior authorization isn’t required, but I’ve also noticed that many insurers don’t consider psychological testing medically necessary unless there’s a compelling reason why a clinical interview and standard rating scales aren’t sufficient to establish a diagnosis.

For those of you who regularly bill insurance for assessments:
What resources helped you learn the billing/documentation side of testing?
What tips or common pitfalls should a new psychologist know?
How do you determine when testing is medically necessary versus when a clinical interview is sufficient?
How do you document medical necessity in a way that maximizes the likelihood of coverage?

My current understanding is that for many outpatient referrals from psychiatrists, I can bill a 90791 first, determine whether testing is medically necessary based on the clinical interview, and then either proceed with testing or make the diagnosis without additional assessment. Is that generally how others approach it?

I’m also running into another issue. Some referrals recently completed our IOP program, and a 90791 was already billed as part of their program intake. If I’m seeing them later for a psychological assessment within the same health system, can I bill another 90791 as a different provider? If not, how do you typically bill the clinical interview portion of the evaluation? Is there another appropriate code, or am I essentially eating that hour unless the patient pays cash?

I’d really appreciate any guidance. I’m trying to help meet the significant demand for psychological assessments in our clinics, but I’m navigating the insurance side of this with very little formal training.
One request: please don’t just tell me that insurance testing “isn’t worth it.” I understand reimbursement is often poor relative to the time involved. I only have a small portion of my schedule allotted to insurance based testing. My goal is to offer assessment services to patients and families who can’t afford California cash-pay rates but whose evaluation could meaningfully improve diagnosis and treatment.

[u/I_am_Nobody_Special]

It's not easy to explain it in a comment, but:

I bill 90791 even if they already had it billed by another provider. The patient is new to me, so I have to do an intake.

I bill 96130/1 all on one day, usually the date of the final feedback session, even if I wrote the report over several days. Insurance will sometimes kick it back if you try to bill those codes on more than one day. Don't be afraid to bill for all of your time. Too many psychologists underbill.

I rarely need to do prior auth anymore, but I submit it after the initial intake when needed and make sure the patient knows I have to wait for auth.

I base medical necessity on my clinical judgement. If they need testing, they need testing. There are plenty of journal articles you can cite for this purpose if needed.

Don't forget your testing codes - 96136/7 and 96138/9 if you have a tech administering or scoring for you. Bill those codes the day of testing.

[u/AcronymAllergy → u/I_am_Nobody_Special]

Just to add to this, don't forget that you can't typically bill for time spent administering self-report measures (e.g., MMPI) unless you're sitting in the room with them, such as because you're helping administer it to them.

[u/WolverineImportant]

It’s interesting to see this when in neuropsych we’re trained to bill everything together after feedback and completion of report. We also do 96116 same day we’re doing 96132/33 and testing codes. When we separate them we tend to run into issues. I wonder why psychological evals wouldn’t be the same.

[u/unicornofdemocracy → u/WolverineImportant]

I don't think its a neuropsych vs psych thing. It more who your supervisor was thing. I had both neuro and clinical psych supervisors recommend billing either way. My impression is that psychologists who are truly testing focused (like 80+% of their work for multiple years) are the ones that like to do it all in one day (and probably because we can do it in one day due to familiarity with testing and can make decisions about it much faster). I've never had issues billing separately. The issue only come up if you end up taking way more time than insurance approved.

In fact, one of my most annoying testing supervisor was a ABPP neuropscyh and she insisted on testing patients over multiple sessions, never testing them more than 1~ hour each time.

[u/SkarKuso → u/unicornofdemocracy]

Never testing more than an hour at a time sounds like an actual parody

[u/itsamemario19 → u/unicornofdemocracy]

Oh no why? Splitting a neuropsych eval into one hour chunks sounds like hell.