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December 2016 Texas Medicaid Provider Procedures Manual

Behavioral Health, Rehabilitation, and Case Management Services Handbook : 6 Physician, Psychologist, and Licensed Psychological Associate (LPA) Providers : 6.11 Psychological and Neuropsychological Testing : 6.11.2 Documentation Requirements

6.11.2
The treating provider must document the medical necessity for the chosen treatment in the client’s medical record and also include the diagnosis code that most accurately describes the client’s condition that necessitated the psychological or neuropsychological testing. The medical record (inpatient or outpatient hospital records, reports, or progress notes) must be signed and dated by the performing provider, and should be clear and concise, documenting the reasons for the psychological or neuropsychological testing and the outcome.
In addition, the following documentation must be maintained by the provider in the client’s medical record:
The name of the tests that were performed (e.g., Wechsler Adult Intelligence Scale–Revised [WAIS‑R], Rorschach, Minnesota Multiphasic Personality Inventory [MMPI]).
The length of time that each provider spent in face-to-face administration, interpretation, reporting the test, integrating the test interpretation, and documenting the comprehensive report based on the integrated data.
Rationale or extenuating circumstances that impact the ability to complete the testing, such as, but not limited to, the client’s condition requires testing over two days and client does not return, or the client’s condition precludes completion of the testing.
The original testing material must be maintained by the provider and must be readily available for retrospective review by HHSC.

Texas Medicaid & Healthcare Partnership
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