Introduction to billing and coding for neuropsychological testing

Insurance companies reimburse providers for two aspects of Cognivue Clarity use:

  1. Use of the Cognivue Clarity® test itself:24
    • In 2019 the American Medical Associate created a distinct procedural code to reimburse providers for administration of neuropsychological testing.
    • This replaces multiple codes previously used for different testing methods25
  2. Time spent integration and the interpretation of the Cognivue Clarity test results into patient care24
    • Evaluation and interpretation of test results
    • Clinical decision making
    • Treatment planning
    • Giving feedback to patients, family members and caregivers.

Documenting the medical necessity of testing

Though payers differ in their documentation requirements, most require that providers show medical necessity to cover the use of the Cognivue Clarity device.

Payers may determine medical necessity based on indication26

Examples include:

  • Deficits on standard mental status testing that require assessment to establish abnormalities
  • When assessment can clarify other test results to establish a clinical diagnosis in neurological or systemic conditions known to affect CNS functioning
  • When assessment is needed to quantify deficits related to CNS impairment for treatment planning purposes
  • When assessment is needed prior to surgery or treatment to evaluate safety of the treatment approach
  • When assessment can determine potential impact of adverse effects of therapies that may cause cognitive impairment

Payers may require documentation of the following to show medical necessity4

  • Cognitive impairment is suspected or has been identified
  • Appropriate treatment or other clinical decision-making cannot commence or continue without quantifying cognitive functioning
  • The questions to be addressed through neuropsychological testing cannot be answered through other means
  • The selected assessment procedures have been established as valid and are likely to be effective
  • The results of testing are likely to have a direct and significant impact on the clinical management of the patient
  • Reasonable effort has been made to obtain and review reports of relevant previous assessments

Payers may reject claims in the following circumstances, which they may not deem medically necessary27

  • Use of testing as a screening instrument when cognitive impairment is not suspected
  • Multiple uses of testing within a certain timeframe
  • Use of testing to diagnose certain cognitive conditions (e.g. learning disabilities, mental retardation, ADHD)

The information in this document is shared for educational and strategic planning purposes only.
While Cognivue, Inc. believes this information to be correct, this document is offered for illustrative or convenience purposes only and does not constitute reimbursement or legal advice. This document does not replace seeking guidance from payers or providers’ coding staff, nor is it a promise or guarantee of payment.