Testing codes for a full evaluation, in order.

The two families of testing codes

Psychological testing is billed in two parts that happen on different days and sometimes by different people.

Evaluation services are the psychologist's clinical work: integrating test data with history and observation, forming the diagnosis, planning treatment, and the feedback session with the family. 96130 is the first hour; 96131 is each additional hour.

Test administration and scoring is giving the tests and scoring them. When the psychologist does it: 96136 for the first 30 minutes and 96137 for each additional 30. When a technician does it under supervision: 96138 and 96139.

Units and time

Evaluation codes count in hours; administration codes count in 30-minute units. Bill the time actually spent, per date of service, and start each date's administration with the base code (96136 or 96138) before add-on units. Two or more standardized tests are required for the administration codes.

Neurobehavioral status exam: 96116

96116 is the clinician's structured assessment of attention, memory, language, executive function, and behavior, first hour, with 96121 for additional hours. It is a distinct service from test administration and from the evaluation service; bill it only when the exam is a documented, separate part of the work.

A worked child evaluation

A comprehensive ADHD evaluation for an eight-year-old on Emora, in code order:

1. Intake and history with the parent, and the referral question from school or pediatrician. Rating scales (parent and teacher) go out.
2. Testing sessions by video: a cognitive measure such as the RIAS-2 and structured observation, delivered with the parent setting up the room and materials as instructed. Billed as 96136 plus 96137 units for the psychologist's administration time, on the dates it happens.
3. Integration: scales, cognitive results, observation, developmental history, and school reports come together into a formulation. Billed as 96130 for the first hour and 96131 for each additional hour.
4. Feedback session with the parents (and the child, when appropriate): findings, diagnosis, recommendations for home and school. Part of the evaluation service hours.
5. Report written for the family, the school, and the pediatrician, and shared into the child's Emora record so the therapist can pick up the plan.

An autism evaluation follows the same shape with the MIGDAS-2 or a comparable observation protocol at the center, plus developmental history and adaptive measures.

Telehealth-delivered testing

Many instruments have publisher guidance for remote administration, and many payers accept telehealth testing with the same modifier and place-of-service rules as therapy. The report should say which instruments were delivered remotely, how standardization was maintained, and any limits on interpretation. Where an instrument cannot be validly delivered by video, say so and choose another. See modifier 95 and place of service 10.

PSYPACT

A psychologist with PSYPACT authority (E.Passport plus APIT) can evaluate a child in any PSYPACT state by telehealth without a second license. That is what lets Emora psychologists serve families across the map. See where psychologists practice with Emora.

What the report must contain

Schools and payers read the report for different things. Both need: the referral question, sources of information, instruments and scores with norms, behavioral observations, developmental and medical history, DSM-5-TR criteria met, the diagnosis, and specific recommendations (classroom supports, therapy targets, medication referral). Schools also want language that maps to eligibility categories and accommodations; write it so a 504 team can act on it. See who can diagnose ADHD and autism, by license.