MedicarE Testing Requirements

These diagnostic tests are used when mental illness is suspected, and clarification is essential for the diagnosis and the treatment plan.

Testing conducted when no mental illness/disability is suspected would be considered screening and would not be covered by Medicare. Non-specific behaviors that do not suggest the possibility of mental illness or disability are not an acceptable indication for testing.

Examples of problems that might require psychological or neuropsychological testing include:

· Assessment of mental functioning for individuals with suspected or known mental disorders for purposes of differential diagnosis or treatment planning.

· Assessment of patient strengths and disabilities for use in treatment planning or management when signs or symptoms of a mental disorder are present.

· Assessment of patient capacity for decision-making when impairment is suspected that would affect patient care or management.

· Differential diagnosis between psychogenic and neurogenic syndromes (e.g., depression versus dementia).

· Detection of neurologic disease based on quantitative assessment of neurocognitive abilities (e.g., mild head injury, anoxic injuries, Acquired Immune Deficiency Syndrome [AIDS] dementia).

· Delineation of the neurocognitive effects of central nervous system disorders.

· Neurocognitive monitoring of recovery or progression of central nervous system disorders.

When a psychiatric condition or the presence of dementia has already been diagnosed, there is value to the testing only if the information derived from the testing would be expected to have significant impact on the understanding and treatment of the patient. Examples include:

· Significant change in the patient’s condition.

· The need to evaluate a patient’s capacity to function in a given situation or environment.

· The need to specifically tailor therapeutic and or compensatory techniques to particular aspects of the patient’s pattern of strengths and disabilities. of the patient’s pattern of strengths and disabilities.

Adjustment reactions or dysphoria associated with moving to a nursing home do not automatically constitute medical necessity for testing. Testing of every patient upon entry to a nursing home would be considered a routine service and would not be covered by Medicare. However, some individuals enter a nursing home at a time of physical and cognitive decline, and may require psychological testing to arrive at a diagnosis and plan of care. Decisions to test individuals who have recently entered a nursing home need to be made judiciously, on a case-by-case basis. Medical necessity of such evaluations should be documented and maintained in the medical record.

Each test administered must be medically necessary. Standardized batteries of tests are only acceptable if each component test is medically necessary.

Depending on the issues to be assessed, a typical test battery may require 7 to 10 hours to perform, including administration, scoring and interpretation.

Formal evaluation of aphasia with an instrument such as the Boston Diagnostic Aphasia Examination performed during treatment, is typically performed only once during treatment and its medical necessity should be documented. If the test is repeated during treatment, the medical necessity of the repeat administration of the test must also be documented.

The following are considered not medically reasonable:

Routine re-evaluation of chronically disabled patients that is not required for a diagnosis or continued treatment is not medically reasonable and necessary. 

Please contact Medicare if you have any questions.

Click here to download and print a neuropsychological evaluation referral form for your referring physician to complete.