Psychological and Neuropsychological Testing

Social Security Act 1861(s) Medical And Other Health Services
Social Security Act 1862(a)(7) does not extend coverage to screening procedures.
42 CFR (Code of Federal Regulations):

410.73 Clinical social worker services
410.74 Physician assistants’ services
410.75 Nurse practitioners’ services
410.76 Clinical nurse specialists’ services

MLN Matters Number SE0441 “Incident to” Services.

CMS Publication 100-02: Medicare Benefit Policy Manual, Chapter 15 - Covered Medical and Other Health Services:

§80.2 Psychological and Neuropsychological Tests
§160 Clinical Psychological Services
§170 Clinical Social Worker (CSW) Services
§210 Clinical Nurse Specialist (CNS) Services

CMS Publication 100-03: Medicare National Coverage Determinations (NCD)Manual, Chapter 1- Coverage Determination, Part 1, Sections 10-80:

§30.1 Biofeedback Therapy

CMS Publication 100-04: Medicare Claims Processing Manual, Chapter 12 - Physicians/Nonphysician Practitioners:

§120 Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS) Services Payment Methodology
§120.1 Limitations for Assistant-at-Surgery Services Furnished by Nurse Practitioners and Clinical Nurse Specialist
§150 Clinical Social Worker (CSW) Services
§160 Independent Psychologist Services
§170 Clinical Psychologist Services
§170.1 Payment

Psychological and neuropsychological tests are designed to determine the functional consequences of known or suspected brain dysfunction through testing of the neuro-cognitive domains responsible for language, perception, memory, learning, problem solving, adaptation, and constructional praxis.

Neurobehavioral Status Examination
A neurobehavioral status exam is completed prior to the administration of neuropsychological testing. The status exam involves clinical assessment of the patient, collateral interviews as appropriate, and review of prior records. The interview includes clinical assessment of several domains including but not limited to; thinking, reasoning and judgment, e.g., acquired knowledge, attention, language, memory, planning and problem solving and visual spatial abilities. The clinical assessment would determine the types of tests and how those tests should be administered (AMA CPT Assistant, November, 2006).

A neurobehavioral status examination, in the absence of neuropsychological testing, is insufficient to diagnose mild cognitive impairment.

Psychological Tests
A psychological test is an instrument designed to measure unobserved constructs, also known as latent variables. Psychological tests are typically, but not necessarily, a series of tasks or problems that the respondent has to solve. Psychological tests can strongly resemble questionnaires, which are also designed to measure unobserved constructs, but differ in that psychological tests ask for a respondent's maximum performance whereas a questionnaire asks for the respondent's typical performance. A useful psychological test must be both valid (i.e., there is evidence to support the specified interpretation of the test results) and reliable (i.e., internally consistent or give consistent results over time, across raters, etc.).

Psychological testing
Psychological tests are used to identify problems in a variety of mental abilities and attributes, such as neuro-cognitive, mental status, achievement and ability, personality, and neurological functioning.

Psychological testing requires a clinically trained examiner. All psychological tests should be administered, scored, and interpreted by a trained professional such as a clinical psychologist, psychologist, advanced nurse practitioner with education in this area, or a physician assistant who works with a psychiatrist with expertise in the appropriate area. The purpose of psychological testing includes the following:

1. To assist with diagnosis and management following clinical findings where a mental illness or psychological abnormality is suspected.
2. To provide a differential diagnosis from a range of neurological/psychological disorders that present with similar constellations of symptoms, e.g., differentiation between pseudodementia and depression.
3. To determine the clinical and functional significance of a brain abnormality.
4. To delineate the specific cognitive basis of functional complaints.

Neuropsychological Testing:
These tests are requested for patients with a history of psychological, neurologic or medical disorders known to impact cognitive or neurobehavioral functioning.

Neuropsychological testing is considered medically necessary for the following indications:

1. When there are mild or questionable deficits on standard mental status testing or clinical interview, and neuropsychological testing is needed to establish the presence of abnormalities or distinguish them from changes that may occur with normal aging, or the expected progression of other disease processes; or
2. When neuropsychological data can be combined with clinical, laboratory, and neuroimaging data to assist in establishing a clinical diagnosis in neurological or systemic conditions known to affect CNS functioning; or
3. When there is a need to quantify cognitive or behavioral deficits related to CNS impairment, especially when the information will be useful in determining a prognosis or informing treatment planning by determining the rate of disease progression; or
4. When there is a need for a pre-surgical or treatment-related cognitive testing to determine whether one might safely proceed with a medical or surgical procedure that may affect brain function (e.g., deep brain stimulation, resection of brain tumors or arteriovenous malformations, epilepsy surgery, stem cell transplant) or significantly alter a patient’s functional status; or
5. When there is a need to test for the potential impact of adverse effects of therapeutic substances that may cause cognitive impairment (e.g., radiation, chemotherapy, antiepileptic medications), especially when this information is utilized to determine treatment planning; or
6. When there is a need to monitor progression, recovery, and response to changing treatments, in patients with CNS disorders, in order to establish the most effective plan of care; or
7. When there is a need for objective measurement of the patient’s subjective complaints about memory, attention, or other cognitive dysfunction, which serves to determine treatment by differentiating psychogenic from neurogenic syndromes (e.g., dementia vs. depression); or
8. When there is a need to establish a treatment plan by determining functional abilities/impairments in individuals with known or suspected CNS disorders; or
9. When there is a need to determine whether a patient can comprehend and participate effectively in complex treatment regimens (e.g., surgeries to modify facial appearance, hearing, or tongue debulking in craniofacial or Down syndrome patients; transplant or bariatric surgeries in patients with diminished capacity), and to determine functional capacity for health care decision-making, work, independent living, managing financial affairs, etc.; or
10. When there is a need to design, administer, and/or monitor outcomes of cognitive rehabilitation procedures, such as compensatory memory training for brain-injured patients; or
11. When there is a need to establish treatment planning through identification and assessment of the neurocognitive sequelae of systemic disease (e.g., hepatic encephalopathy; anoxic/hypoxic injury associated with cardiac procedures); or
12. Assessment of neurocognitive functions for the formulation of rehabilitation and/or management strategies among individuals with neuropsychiatric disorders; or
13. When there is a need to diagnose cognitive or functional deficits in children and adolescents based on an inability to develop expected knowledge, skills or abilities as required to adapt to new or changing cognitive, social, emotional, or physical demands.

Examples of problems that might lead to neuropsychological testing include:

1. Detection of neurologic diseases based on quantitative assessment of neurocognitive abilities (e.g., mild head injury, anoxic injuries, AIDS dementia); 
2. Differential diagnosis between psychogenic and neurogenic syndromes; 
3. Delineation of the neurocognitive effects of CNS disorders; 
4. Neurocognitive monitoring of recovery or progression of CNS disorders; and/or 
5. Assessment of neurocognitive functions for the formulation of rehabilitation and/or management strategies among individuals with neuropsychiatric disorders. 
6. Determining the management of the patient by confirmation or delineation of diagnosis.

Components of Neuropsychological Testing

1. Test Selection
   Information from medical records, clinical interviews, and behavioral observations is integrated to guide the selection of specific neuropsychological tests. The selection of tests is a strategic process that varies as a function of patient characteristics (level of education, premorbid level of functioning, sensory abilities, physical limitations, fatigue level, age, and ethnicity) and the goals of the testing (establishing a diagnosis, measuring treatment effects, etc.).
2. Test Administration and Scoring 
   Tests are administered either directly by a Medicare provider with an appropriate state license or by a trained technician. A technician who administers the neuropsychological test must be directly supervised by the provider.
   
   Neuropsychological tests include direct question-and-answer, object manipulation, inspection and responses to pictures or patterns, paper-and-pencil written or multiple choice tests, which measure functional impairment and abilities in:
   
   a. General intellect
   b. Reasoning, sequencing, problem-solving, and executive function
   c. Attention and concentration
   d. Learning and memory
   e. Language and communication
   f. Visual-spatial cognition and visual-motor praxis
   g. Motor and sensory function
   h. Mood, conduct, personality, quality of life
   i. Adaptive behavior (Activities of Daily Living)
   j. Social-emotional awareness and responsivity
   k. Psychopathology (e.g., psychotic thinking or somatization)
   l. Motivation and effort (e.g., symptom validity testing)

Limitations of Coverage:
Psychological and Neuropsychological testing is considered not reasonable and necessary when:

1. The patient is not neurologically and cognitively able to participate in a meaningful way in the testing process, or 
2. Used as screening tests given to the individual or to general populations [Section 1862(a)(7) of the Social Security Act does not extend coverage to screening procedures], or 
3. Administered for educational or vocational purposes that do not establish medical management, or 
4. Performed when abnormalities of brain function are not suspected, or 
5. Used for self-administered or self-scored inventories, or screening tests of cognitive function (whether paper-and-pencil or computerized), e.g., AIMS, Folstein Mini-Mental Status Examination, or 
6. Repeated when not required for medical decision-making (i.e., making a diagnosis or deciding whether to start or continue a particular rehabilitative or pharmacologic therapy), or 
7. Administered when the patient has a substance abuse background and any of the following apply:
   
   a. the patient has ongoing substance abuse such that test results would be inaccurate, or
   b. the patient is currently intoxicated, or
8. The patient has been diagnosed previously with brain dysfunction, such as Alzheimer’s diseases and there is no expectation that the testing would impact the patient's medical management, or 
9. The test is administered solely as a screening test for Alzheimer's disease - Medicare does not cover screening for this diagnosis.

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Documentation Requirements

1. The medical record and assessment report should document the diagnosis and treatment recommendations.
2. The patient’s medical record should contain documentation that fully supports the medical necessity for testing performed. This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Documentation should include the following information:
a. any suspected mental illness or neuropsychological abnormality or central nervous system dysfunction
b. the initial clinical findings that determine the need for testing
c. the types of testing indicated
d. the time involved and whether this is initial testing or follow-up
e. previous testing by the same or different provider, and efforts to obtain previous test results performed
f. the test(s) administered, scoring and interpretationg. treatment recommendations
3. Documentation should be legible, signed, and maintained in the patient's medical record. Upon request it must be available to the Medicare Contractor.
4. If the total time for the tests exceeds eight hours, a report may be requested asking for the medical necessity of the extended testing.
5. The administration of psychological testing and/or neuropsychological testing must result in the generation of material that will be formulated into a report that will be given to the referring provider.

Utilization Guidelines
The services in this LCD do not represent psychotherapeutic modalities, but are diagnostic aids. Each test performed must be medically necessary and therefore, standardized batteries of tests are not acceptable, unless the use of each test in the battery is medically necessary.

Self-administration or self-scored inventories such as the Holmes and Rahe Social Readjustment Rating Scale or screening tests of cognitive function such as the Folstein Mini-Mental Exam (or similar tests) is not separately reimbursable by Medicare and is included in the clinical interview or E/M service.

Patients with psychiatric disorders where the needed information can be obtained through the clinical interview alone (e.g., response to medication) would not require psychological testing and such testing would not be considered medically necessary.

Adjustment reaction or dysphoria associated with moving to a nursing facility does not constitute medical necessity for psychological testing.

The time selected for billing purposes include face-to-face administration and scoring for the neuropsychological test(s).

American Academy of Clinical Neuropsychology (2010). AACN response to AMA/PCPI Dementia Performance Measurement Set.

American Academy of Clinical Neuropsychology (2011). AACN letter to the Wisconsin Physicians Service on LCD.

American Medical Association (2006). CPT Assistant. American Medical Association.

Ethical American Psychological Association (2010). Principles of Psychologists and Code of Conduct.

Beck, I. R., Gagneux-Zurbriggen, A., Berres, M., Kirsten, I.T., & Monsch, A.U. (2012). Comparison of verbal episodic memory measures: Consortium To Establish A Registry For Alzheimer’s Disease-Neurophsychological Assessment Battery (CERAD-NAB) versus California Verbal Learning Test (CVLT). Archives of Clinical Neuropsychology, 27, 510-519.

Cosentino, S., Metcalfe, J., Cary, M., De Leon, J., & Karlawish, J. (2011). Memory awareness influences everyday decision-making capacity about medication management in Alzheimer's disease. International Journal of Alzheimer's Disease, Article ID 483897, 9 pages.

Cummings, J., Jones, R., Wikinson, D. Lopez, O. et al (2010). Effect of donepezil on cognition in Alzheimer’s disease: a pooled data analysis. Journal of Alzheimer’s Disease, 21, 843-851.

Farias, S. T., Harrell, E., Neumann, C., & Houtz, A. (2003). The relationship between neuropsychological performance and daily functioning in individuals with Alzheimer's disease: ecological validity of neuropsychological tests. Archives of Clinical Neuropsychology, 18, 655-672.

Gavett, B. E., Lou, K. R., Daneshvar, D. H., Green, R. C., Jefferson, A. L., & Stern, R. A. (2012). Diagnostic accuracy statistics for seven Neuropsychological Assessment Battery (NAB) test variables in the diagnosis of Alzheimer's disease. Applied Neuropsychology: Adult, 19(2), 108-115.

Jak, A. J., Bondi, M. W., Delano-Wood, L., Wierenga, C., Corey-Bloom, J., Salmon, D. P., et al. (2009). Quantification of five neuropsychological approaches to defining mild cognitive impairment. American Journal of Geriatric Psychiatry, 17, 368-375.

Neuropsychology Model LCD Taskforce, a national workgroup representing The American Academy of Clinical Neuropsychology (AACN), the American Psychological Association (APA) Division of Clinical Neuropsychology, and the National Academy of Neuropsychology (NAN), July 2011.

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