Psycl tst eval phys/qhp 1st
CPT code 96130 covers the first hour of psychological or neuropsychological test evaluation performed by a physician or qualified healthcare professional. This is the professional work of reviewing test results, interpreting data, and preparing a clinical report—not the test administration itself.
This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
NCCI bundling edits
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Billing tips
Bill 96130 for the first hour of evaluation only; use add-on code 96131 for each additional hour to capture full professional time
Impact: Add-on code 96131 reimburses approximately $112 per additional hour; failure to bill can result in 50% revenue loss for multi-hour evaluations
Document exact start and stop times for evaluation activities including data review, integration, interpretation, and report preparation
Impact: Time documentation is critical for audit defense; vague time records are the #1 reason for $117.42 claim denials and recoupments
Do not bill 96130 on the same date as 96136-96139 (test administration codes) unless performed by different qualified professionals or clearly distinct sessions
Impact: Bundling edits may reduce payment by 50% or deny secondary service; proper modifier use and documentation prevents $106-117 loss per claim
Ensure medical necessity is clearly established in referral and documentation with specific diagnostic questions the testing will address
Impact: Medical necessity denials account for 30-40% of psychological testing claim rejections; clear documentation protects full $117.42 reimbursement
Bill in the non-facility setting when performed in private office to capture the higher rate of $117.42 versus $106.10 facility rate
Impact: Place of service code determines $11.32 difference per claim; incorrect POS coding costs practices thousands annually
Verify that testing protocols and interpretation are appropriate to the patient's diagnosis code; align CPT with ICD-10 code medical necessity
ICD-10 mismatch is a common denial trigger; proper alignment prevents payment delays and maintains 2.56 work RVU credit
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