CNS Vital Signs Reimbursement

Reimbursement for CNS Vital Signs is generally well accepted by most payers. CMS/Medicare provided guidance in 2006 mandating coverage for the current billing codes. Generally, most payers follow CMS’s guidance and that has remained so with payment for neurocognitive assessment procedures. Practitioners know that payer’s rules for reimbursement can vary greatly, but in general, neurocognitive assessment procedures are billable and reimbursable.

WHY do Payers Reimburse a CNS Vital Signs Procedure?

Most payers consider computerized neurocognitive assessment procedures medically necessary because the assessment procedure aids in the assessment of neurocognitive impairment due to medical or psychiatric conditions. Examples of medical conditions that can benefit the evaluation and management of patients include, but are not limited to:

• Assessment of neurocognitive abilities following traumatic brain injury, stroke, or neurosurgery or relating to a medical diagnosis, such as multiple sclerosis, epilepsy, hydrocephalus or AIDS.
• Assessment of neurocognitive functions to assist in the development of rehabilitation and/or management strategies for persons with diagnosed neurological disorders.
• Needed in the differential diagnosis between psychogenic and neurogenic syndromes.
• Monitoring of the progression of neurocognitive impairment e.g., Multiple Sclerosis, effects of aging, etc.
• Pre-surgical clearance. An evaluation is sometimes required e.g., Obesity Surgery.
• Pre-radiological clearance. A serial evaluation of neurocognitive decline is sometimes required e.g., Alzheimer’s PET scan.
• Brief-Core neurocognitive testing and rating scales are needed to aid in the intake or initial assessment of neurobehavioral (96116) or psychiatric (90801) conditions.
• Serial assessment is needed to evaluate treatment effects, develop treatment recommendations after a patient has been tried on various medications and/or psychotherapy, has not progressed in treatment, and continues to be symptomatic. CNS Vital Signs generates longitudinal views that are beneficial in tracking outcomes.
• Neurocognitive assessment may also be used in occupational or environmental medicine conditions e.g., evaluating the impact of chronic solvent or heavy metal exposure. In these cases, Neurocognitive testing may be covered by the worker's compensation carrier.
• Worker's compensation carriers may also provide coverage for neurocognitive assessments for disability qualification, or legal/court-related purposes.

Coverage for neurocognitive procedures can be covered in the MENTAL HEALTH BENEFIT (e.g., psychiatric illness, depression, AD/HD, alcohol and/or drug abuse, schizophrenia, etc.) or the MEDICAL BENEFIT (e.g., neurological conditions like multiple sclerosis, memory conditions like MCI - Alzheimer's disease, traumatic brain injury, stroke, differentiation of brain damage from a depressive disorder, epilepsy, MHE, hydrocephalus, Parkinson disease, AIDS, etc.)

ABOUT AD/HD: Neurocognitive assessments may be deemed medically un-necessary for uncomplicated (primary care, school psychologist) cases of attention deficit disorder with/without hyperactivity (ADHD). If a patient is clearly seeking the testing for educational reasons e.g., special accommodations such as extended time on testing or other special services in school, these services generally, are provided by school systems under applicable state and federal rules and generally are not reimbursed by insurance carriers. Most benefit plans exclude coverage of educational testing. Check the patients benefit plan as payment may need to be paid directly to the practice by the patient for the services. However, many employer based benefits have special set-aside health accounts that can be used for payment of neurocognitive assessments for AD/HD if the health plan deems the procedure medically unnecessary.

However, health plans may reimburse and consider the procedure medically necessary for the evaluation and management of complicated cases e.g. executive dysfunction, examining expanded developmental concerns, neurologically complicated cases of ADHD, e.g., post head trauma, seizures, or comprehensive bio-psychosocial treatment for these disorders in collaboration with primary care physicians and other specialists.

ABOUT MEMORY - HEALTHY AGING: Neurocognitive assessment procedures are also used in the initial evaluation of neurocognitive deterioration associated with aging. It is also used to assess persons with deteriorating neurocognitive functioning to distinguish between amnestic and non-amnestic MCI as well as diminished function or worsening of the disease. Serial administration of tests has been employed to investigate the effects of cholinergic agents and other drugs. The DSM-5 is currently proposing a revised diagnostic category “Neurocognitive Disorders” replacing the DSM-IV Category of ―Delirium, Dementia, Amnestic, and Other Geriatric Cognitive Disorders". In the DSM documents it says “The defining characteristics of these disorders are that their core or primary deficits are in neurocognition and that these deficits represent a decline from a previously attained level of cognitive functioning.” CNS Vital Signs provides objective assessments that can be used to document and quantify the degree of impairment(including assessment of changes over time or in response to intervention). CMS – Medicare has mandated coverage and expanded the assessment procedure coverage to many types of providers.

HOW do I Bill for Assessment Procedure Services?

In November 2005, the American Medical Association’s (AMA) CPT Editorial Panel announced it is replacing the existing Current Procedural Terminology (CPT)® Central Nervous System Assessments codes with an expanded set of codes beginning Jan. 1, 2006. The CNS assessment codes were again updated in 2008.

“Central Nervous System Assessments / Tests Billing Codes e.g., Neuro-Cognitive, Mental Status” are the codes used when billing for a CNS Vital Signs neurocognitive procedure.

The Central Nervous System Testing Codes are used to report the procedure services provided during testing of the neurocognitive pathophysiology and neural systems of the central nervous system. The testing of neurocognitive processes, visual motor responses and abstractive abilities is accomplished by the combination of several types of testing procedures.

The CNS Vital Signs VSX BRIEF-CORE assessment procedure contains seven separate tests of brain function that are auto-scored into nine clinical domains, the VSNP (expanded normed battery) and VSR have additional tests and domains and all three assessment procedures are well-established methods for evaluating patients who demonstrate neurocognitive or behavioral abnormalities. CNS Vital Signs is also used in combination with validated paper and pencil based testing and billed using the same codes. In general, Payers expect that the administration of these testing services will generate material that will be formulated and integrated into a report.

Neurocognitive testing such as CNS Vital Signs helps clinicians better understand the nature of their patient’s illness, in making recommendations regarding coping with and compensating for their neurocognitive difficulties, and encourages treatment adherence. Ultimately, the data accumulated from administering CNS Vital Signs can be used as an outcome measure or for generating clinical insights that improve future care strategies.

CNS Vital Signs provides an OBJECTIVE, PRECISE, STANDARDIZED, and CORE set of neurocognitive or brain function clinical endpoints which supports many neuro-psych clinical guidelines and provides clinicians with a tool to enable evidence based medicine. There are generally two possible procedure coding events… (1) a testing, interpretation, and reporting event and (2) the time a clinician takes INTEGRATING (96101, 96118) the test results into other sources of clinical testing data.

Psychological and Psychiatric Assessment Codes

90801 - Psychiatric diagnostic interview exam is a single un-timed service for the elicitation of a complete medical and psychiatric history, a mental status examination, establishment of a tentative initial diagnosis, and an evaluation of the patient's ability and capacity to respond to treatment on an initial plan of treatment.
96101 - Testing & Interpretation - Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, cognition, personality and psychopathology, e.g., MMPI, Rorschach, WAIS, CNS Vital Signs), per hour of the qualified healthcare professional time, both face-to-face time administering tests to the patient and time interpreting test results and preparing the report.
96101 - Additional Professional - is also used in those circumstances when additional time is necessary to integrate other sources of clinical data, including previously completed and reported technician and computer administered tests
► (Do not report 96101 for the interpretation and report of 96102, 96103) ◄
96102 - Testing & Interpretation -Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, cognition, personality and psychopathology. e.g., MMPI, CNS Vital Signs, and WAISI), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face.
96103 - Testing & Interpretation - Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI, CNS Vital Signs), administered by a computer, with qualified health care professional interpretation and report.
96105 – Testing and Interpretation - Assessment of aphasia {includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour.
96111 - Testing & Interpretation – Developmental testing extended (includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments including CNS Vital Signs) with interpretation and report.

Neuropsychological and Neurological Assessment Codes

96116 - Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, e.g., acquired knowledge, attention, language, memory, planning and problem Striving, and visual spatial abilities), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report.
961118 - Testing & Interpretation - Neuropsychological testing (e.g., Halstead - Reitan Neuropsychological Battery, Wechsler Memory Scales, CNS Vital Signs and Wisconsin Card Sorting Test), per hour of the qualified healthcare professional time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report.
961118 - Additional Professional - 96118 is also used in those circumstances when additional time is necessary to integrate other sources of clinical data, including previously completed and reported technician- and computer-administered tests.
►(Do not report 96118 for the interpretation and report of 96119 or 96120) ◄
96119 - Testing & Interpretation - Neuropsychological testing (e.g. Halstead - Reitan Neuropsychological Battery, Wechsler Memory Scales, CNS Vital Signs 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 - Testing & Interpretation - Neuropsychological testing (e.g. Wisconsin Card Sorting Test, CNS Vital Signs), administered by a computer, with qualified health care professional interpretation and report.
96125 - Testing & Interpretation - Standardized cognitive performance testing (e.g. Ross Information Processing Assessment) per hour of a qualified health care professional's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report.

About 96118 and 96101… These Codes are reported for psychological and neuropsychological test administration by the qualified health care professional with subsequent interpretation and report. It is also reported for the integration of information obtained from other sources which is then incorporated in the more comprehensive interpretation of the meaning the tests results in the context of all testing and assessments. The administration of the tests is completed for the purposes of a physical health diagnosis. The potentially confusing aspect of this code is that when the qualified health care professional performs the tests personally, the test specific scoring and interpretation is counted as part of the time of 96101 and 96118. Adapted from: AMA CPT Assistant, November, 2006

About 96103 and 96120… These Codes are reported for the computer-administrated psychological and neuropsychological testing, with subsequent interpretation and report of the specific tests by a qualified health care professional. This should be reserved for situations where the computerized testing is unassisted by a provider or technician other than the installation of programs/test and checking to be sure that the patient is able to complete the tests. If greater levels of interaction are required, though the test may be computerized administer, then the appropriate physician/psychologist (96101/96118) or technician code (96102/96119) should be used. Adapted from: AMA CPT Assistant, November, 2006

About 96116 and 90801… A neurobehavioral status exam or psychiatric diagnostic interview exam is completed prior to the administration of psychological - neuropsychological testing. The status exam involves the clinical in-take assessment of the patient, collateral interviews (as appropriate and review of prior records. The interview would involve clinical assessment of several domains including but 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. Adapted from: AMA CPT Assistant, November, 2006 (NOTE: Clients have reported using the CNS Vital Signs BRIEF-CORE neurocognitive test and the NPQ-207 as part of their standard in-take process and then bill using these codes.)

Additional Information: Codes 96101 and 96118 were revised in 2008 to clarify and differentiate appropriate reporting of services by the psychologist or physician from those testing services performed by the technician or computer administered tests (96102 -96119 and 96103 - 96120). The revisions emphasize that the services reported with the time-based code (96101 - 96118) are reported for clinician administered testing, interpretation of the results, report preparation, AND any additional necessary time for the integration of the test data acquired from the computer, technician testing or other data (paper & pencil) into the report. Modifier is not applicable if the professional provides the service. If the technician provides the service, clients should investigate the use of the 59 modifier. Many payers have required the modifier be applied to any of the testing codes though probably best to attach to technician and/or computer codes (CMS, September, 2006). Simultaneous Use of Professional and Technical Codes Allowed by Medicare MLN Matters: MM5204 Revised, Effective December 28, 2006.

Suggestions for Documentation:

CMS (Recovery Audit Program) and other payers have active and ongoing audit programs to recover fraudulent claims. Clients have expressed the following tips to help a practice be prepared for an audit.

• Technical Component – Label whether Tech admin or Computer admin, Number of Tests.
• Professional Component – Label Activities: Testing by Professional, Interpretation, Report, or Integration of findings which may include history, prior records, interview(s), and compilation of tests. 
• Testing Time – KEY ADVANTAGE: CNS Vital Signs Time and Date stamps all assessments. For Paper and Pencil testing minimum documentation should be: Date(s) & Total Time Elapsed, Maximum: Date(s) Start and Stop Times; Testing Time Backup - Scheduling System (e.g., schedule book; agenda, etc), Testing Sheet with Lists of Tests with Start/Stop Times, Keep Time Information as long as records are kept. *Medical Necessity can vary by Payer.

Functional Magnetic Resonance Imaging CPT Codes (CNS Vital Signs has also been used in fMRI testing)

70554 - Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration. [Do not report 70554 in conjunction with 96020] [Do not report 70554, 70555 in conjunction with 70551-70553 unless a separate diagnostic MRI is performed]
70555 - Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing. [Do not report 70555 unless 96020 is performed] [Do not report 70554, 70555 in conjunction with 70551-70553 unless a separate diagnostic MRI is performed]
96020 - Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or psychologist, with review of test results and report. [For functional magnetic resonance imaging (fMRI), brain, use 70555] [Do not report 96020 in conjunction with 70554] [Do not report 96020 in conjunction with 96101-96103, 96116-96120] [Evaluation and Management services codes should not be reported on the same day as 96020]

About 96020… Pre-operative neurofunctional planning during MR imaging may require interaction with a physician or psychologist or may be performed by a technologist or physicist. When neurofunctional testing is performed by an individual other than a physician or psychologist, CPT code 70554 should be reported. When the fMRI procedure requires interaction with a physician or psychologist, the procedure is not limited to physicians of a particular specialty (i.e., neurologists, neurosurgeons, neuropsychologists) but instead may be performed by any qualified provider. Codes 70555 and 96020 are used in conjunction to report pre-operative neurofunctional MRI testing administered entirely by a physician or psychologist, as indicated. CPT code 70555 is used to report the fMRI while CPT code 96020 is used to report the testing component by the physician or psychologist. The physician or psychologist is responsible for “selection and administration of testing of language, memory, cognition, movement, sensation, and other neurological functions when conducted with functional neuroimaging, monitoring of performance of this testing, and determination of validity of neurofunctional testing relative to separately interpreted functional magnetic resonance images”. The testing component of functional brain mapping described in CPT code 96020 encompasses the psychological, neuropsychological and neurobehavioral testing methodologies (CPT codes 96101-96103 and 96116-96120); therefore, CPT code 96020 should not be reported in conjunction with these other codes as indicated in Table 1 above. Additionally, the evaluation and management services codes should not be reported on the same day as 96020.

WHO can Bill these Codes?

Neuropsychological / Neurocognitive assessments are defined as testing that is intended to diagnose and characterize the neurocognitive effects of medical disorders that impinge directly or indirectly on the brain. CNS Vital Signs produces a valid and reliable assessment of your patients’ mental functions and processes. Neuropsychological tests differ from psychological tests in that neuropsychological testing consists primarily of individually administered ability tests that comprehensively sample a patients cognitive ability domains that are known to be sensitive to the functional integrity of the brain (e.g., abstraction, memory, attention, language, problem-solving, sensory and motor functions, constructional praxis). These tests are objective and quantitative and require the patient to directly demonstrate his or her level of confidence in a particular neurocognitive domain.

Generally, all payers reimburse neurocognitive assessments done by brain and behavioral sub-specialists, neuropsychologists, neurologists, psychiatrists, and clinical / developmental psychologists. Additionally, CMS and other payers reimburse other qualified health professionals e.g. physicians, physician assistants, nurse practitioners, and other allied health professionals. Review provider coverage with each health plan is recommended.

Additional Reimbursement Information

A solid reimbursement strategy is critical for the success of the practice when a new or existing clinical testing procedure is adopted. Within this strategy, the critical elements of coverage, coding, and payment must be thoroughly understood combined with a positive, persistent determination to persuade carriers that “THIS NEW ASSESSMENT IS AN IMPROVEMENT IN PATIENT CARE AND PROVIDES BOTH EFFECTIVE AND EFFICIENT CARE!” Most payers reimburse for neurocognitive / neuropsychological testing, however, clients report that a proactive reimbursement plan maybe beneficial to your clinics performance. At patient enrollment: Collect the necessary payer data from the patient, Gain verification of eligibility, Obtain any prior authorizations, if required, and Provide the insurance company with the referral (medical) diagnosis and the proposed procedure codes. Also: Find out from the insurance company whether the patient has benefits for neurocognitive or neuropsychological diagnosis and procedures, whether there are any limits on that coverage, and the actual rate of reimbursement for each unit of the procedure. Information should be communicated to the patient / family so that they will know the exact nature of the financial responsibility they are assuming. Remember, many employer funded plans allows the beneficiary (your patient) the opportunity to place tax free monies into special accounts that can be used on procedures that are not covered by the health plan.

With the growing public health concerns about conditions such as Memory Loss (mild cognitive impairment, dementia), AD/HD, Stroke/Brain Injury, Multiple Sclerosis and Mood Disorders; CNS Vital Signs represents a major advancement in patient care, which will enable clinicians and practices to more affordably manage their patient’s neurocognitive status.

Clinicians know that good health has many dimensions, but none are more important than the health of a patient’s brain. Neurocognitive status is increasingly being recognized as a major factor in determining a person’s quality of life and neurocognitive testing helps clinicians evaluate the health of the higher functions of the brain. As part of CNS Vital Signs commitment to advancing patient access to neurocognitive testing, we work with Public Payers such as the Centers for Medicare and Medicaid Services (CMS), and Private Payers such as health insurers to help ensure appropriate reimbursement for services involving our products.

Disclaimer: The information provided in this document was obtained from third-party sources and is subject to change without notice as a result of changes in reimbursement laws, regulations, rules, and policies. All content on this document is informational only, general in nature, and does not cover all situations or all payers’ rules and policies. This content is not intended to instruct medical providers on how to use or bill for healthcare procedures, including new technologies outside of Medicare national guidelines. A determination of medical necessity is a prerequisite that CNS Vital Signs assumes will have been made prior to assigning codes or requesting payments. Medical providers should consult with appropriate payers, including Medicare fiscal intermediaries and carriers, for specific information on proper coding, billing, and payment levels for healthcare procedures. This information represents no promise or guarantee by CNS Vital Signs concerning coverage, coding, billing, and payment levels. CNS Vital Signs specifically disclaims liability or responsibility for the results or consequences of any actions taken in reliance on this information.