Understanding CPT Code 96137: When and How to Use It Correctly

If you work in behavioral health billing, you're likely familiar with the CPT code 96137, but may have questioned if it should be included in your billing process. There is no simple solution. Often, behavioral health billers, coders and practice managers find themselves in a gray area with CPT code 96137. 

It is a code for psychological and neuropsychological testing, but can be used in behavioral health and care under certain clinical circumstances. Understanding exactly when code 96137 is covered and when it is not and why claims are denied is crucial to protect the revenue cycle.

What CPT Code 96137 Actually Means for Billers

CPT code 96137 describes psychological or neuropsychological test administration and scoring by a physician or other qualified healthcare professional. It covers two or more tests using any method, for each additional 30 minutes beyond the initial period. It is an add-on code; meaning it cannot be billed independently. 

The first 30 minutes of test administration will always use the main of 96136 and will always be used with the CPT 96137. This is one of the first things to get correct when billing behavioral health claims with code 96137.

In 2019, CMS removed the old codes 96103 and 96101 and replaced them with the current codes that align testing codes with actual clinician workflow including 96136, 96137, 96138, 96139 and others. Knowing this history will help billers recognize why this code may be used inappropriately in behavioral health practices today.

When CPT Code 96137 Is Billable in Behavioral Health

In behavioral health there are legitimate clinical situations that allow for the use of CPT 96137. This code is even more important in behavioral health because of the complexity of the patients treated. Patients with substance use disorders, psychiatric comorbidities, cognitive impairment (chronic substance use), or traumatic brain injury may frequently need to undergo comprehensive testing batteries.

If the person conducting the testing personally administers and scores 2 or more standardized psychological tests and the testing exceeds the first 30 minutes reported with CPT code 96136, then 96137 CPT code is billable for each additional 30 minutes of testing. This code is appropriate for standardized assessment activities performed by the clinician, and it is important that documentation supports the service billed.

For instance, 90 minutes is spent administering a comprehensive assessment to a patient with co-occurring SUD and ADHD, the first 30 minutes would be billed as 96136 and the next two 30 minutes would be billed as 96137. This is an appropriate CPT 96137 use case in behavioral health.

The extra 30-minute increments of time count as provider administered testing and are billed using the 96137 CPT code for provider admin time, with the minimum time requirement of 16 minutes per unit. This time period is important. You can't bill an extra unit of CPT code 96137 for the last testing block if the block is not at least 16 minutes.

When CPT Code 96137 Is Not Covered in Behavioral Health

This is where the majority of behavioral health practices get in trouble. CPT code 96137 is not suitable for behavioral health therapy or counseling services that are occurring on a regular basis. It is directly related to administration and scoring of formal standardized psychological or neuropsychological tests. If your practice is not doing this type of structured testing, don't use 96137 CPT code on your claims.

Psychological and neuropsychological testing is most frequently done for members with psychological symptoms. If the test was conducted for an “important medical diagnostic purpose,” the claim may not be eligible for coverage under the member's behavioral health benefit, and the provider may want to submit the claim to the member's medical insurance carrier.

This is an important aspect for behavioral health billers. If the primary reason for testing is medical or neurological, not behavioral or psychiatric, then 96137 CPT code  might not even be covered under the behavioral health benefit and may be referred to the medical benefit. One of the most common reasons for claims denial is when a provider bills the 96137 CPT code for medically driven testing under the behavioral health benefit.

Behavioral Health Providers Who Can Bill CPT Code 96137

Not all behavioral health providers are able to bill 96137 CPT code. Psychological and neuropsychological testing services should only be conducted by an appropriately trained and licensed psychologist, physician, or behavioral health qualified healthcare professional. 

Licensed clinical social workers, LCSWs; licensed counselors, LCs; and marriage and family therapists, MFTs, generally are not allowed to bill CPT code 96137, since their state license and payer contracts do not usually allow them to perform and bill for psychological testing services.

96137 CPT code  will only be used if the test is administered by a licensed provider, like a psychologist or physician. Note that when a technician is supervised while performing testing, the testing codes are 96138 and 96139, rather than 96136 and 96137. The compliance issue is if the test was actually conducted by a technician, then using CPT code 96137 is a mistake that could lead to an audit and a repayment request.

Top Denial Reasons for CPT Code 96137 in Behavioral Health

It is not uncommon for claims to be denied when coding CPT code 96137 in behavioral health services. These are the most common reasons for denials that billers should know about.

The most common denial is where 96137 is submitted without the primary code 96136 on the same claim. Add-on codes will always be added to the primary standalone code and must be on the same date of service, the same claim form and the same patient. 

The second type of denial is wrong time recording. Common revenue and audit risk challenges that practices can face include incorrect time tracking, using the wrong unit calculation, and not documenting extended administration time. 96137 CPT code  will be denied for notes that are not clear as to how many minutes were spent for each testing block in the test administration.

The third denial reason is when you bill under the incorrect benefit for CPT code 96137. If the medical reason for the testing, it will be denied by the behavioral health payer as explained earlier. Billers must check to see which benefit will cover the testing prior to submitting CPT code 96137.

The fourth denial is for prior authorization. Psychological and neuropsychological testing are frequently pre-authorized for payment. 96137 CPT code  will be denied without an approved authorization, and there is limited ability to appeal a denial of this code.

When the fifth denial occurs it is due to an unqualified provider's billing of CPT code 96137. The claim for CPT code 96137 will be denied due to provider eligibility if the rendering provider is not eligible to perform psychological testing as specified in the Payer's policy.

How to Appeal CPT Code 96137 Denials Successfully

Don't give up on the 96137 CPT code after receiving a denial. There are a lot of denials that can be retrieved if it is the correct appeal. First, find the denial reason in the explanation of benefits. If the claim is denied because of the lack of the primary code, resubmit the claim with the corrected primary code, 96136 and 96137. If you have already been paid for the base standalone code, you must comply carefully with the resubmission process for that code by your payer because the process remains the same and the time limits are still in force.

Include detailed session notes with documentation for denials for CPT code 96137: For documentation-related denials, include clear session notes that detail the tests administered, the time spent on each test, and the total time spent on the test(s) (billable time). If a payer has a retrospective authorization process, please follow it for authorization denials.

Payer Specific Rules Affecting CPT Code 96137 Coverage

CPT Code 96137 is handled differently by different payers when it comes to behavioral health. Medicare does not deviate much from the guidelines set by CMS and the rendering provider must have a valid Medicare provider number and be licensed in the state in which the service is provided. 

Commercial payers and Medicaid managed care plans may have their own medical policies that outline which diagnoses, provider types and settings are covered under 96137 reimbursement. Before submitting 96137 CPT code  to the payer, review the payer's policy for behavioral health coverage.

How Behavioral Health RCM Services Helps You Bill Correctly

Billing CPT codes in a behavioral health setting requires precision, payer knowledge, and proper documentation. Behavioral Health RCM Services is a behavioral health billing and coding firm dedicated to nothing but behavioral health. We confirm provider credentials, check prior authorization requirements, ensure the payer-specific policies are met and verify that every claim is submitted the right way, with the right code pairing and accurate time units before it is even submitted to the payer.

If a claim is rejected, we take immediate action. We determine the denial reason, prepare a robust appeal including documentation, and resubmit within the appeal filing deadline. As a solo psychologist or a large behavioral health organization, our team ensures that your claims are clean, your denials are low and your revenue is consistent.

Conclusion

CPT code 96137 is not a simple code for behavioral health billing. It has clinical needs, documentation guidelines, and insurance policy requirements that differ by each Medicare, Medicaid, and commercial insurance company. When used correctly it aids in capturing the whole value of longer psychological testing services. If not used as it should be, it's one of the most denial-prone codes in your workflow.

Always use 96137 CPT code  along with CPT code 96136, check that your provider is qualified, be sure to record test names and time blocks accurately, and confirm the payer requirements before providing the service. 

Contact Behavioral Health RCM Services today to take the stress out of billing and strengthen your revenue cycle if you're having trouble with CPT code 96137 denials.

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