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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 3 School Health and Related Services (SHARS) : 3.3 Services, Benefits, Limitations, and Prior Authorization : 3.3.3 Psychological Testing and Services

3.3.3
3.3.3.1
Evaluations or assessments include activities related to the evaluation of the functioning of a student for the purpose of determining eligibility, the needs for specific SHARS services, and the development or revision of IEP goals and objectives. An evaluation or assessment is billable if it leads to the creation of an IEP for a student with disabilities who is eligible for Medicaid and who is 20 years of age or younger, whether or not the IEP includes SHARS.
Evaluations or assessments (procedure code 96101) must be provided by a professional who is a licensed specialist in school psychology (LSSP), a licensed psychologist, or a licensed psychiatrist in accordance with 19 TAC §89.1040(b)(1) and 34 CFR §300.136(a)(1).
Evaluation or assessment billable time includes the following:
A parent/teacher consultation with the student present that is required during the assessment because a student is unable to communicate or perform certain activities
Time spent gathering information without the student present or observing a student is not billable evaluation or assessment time.
Session notes are not required; however, documentation must include the billable start time, billable stop time, total billable minutes, and must note which assessment activity was performed (e.g., testing, interpretation, or report writing).
3.3.3.1.1
 
Important:
One unit (1.0) is equivalent to one hour or 60 minutes. Providers may bill in partial hours, expressed as 1/10th of an hour (six-minute segments). For example, express 30 minutes as a billed quantity of 0.5.
Refer to:
When billing, minutes of Evaluations or Assessments are not accumulated over multiple days. Minutes of Evaluations or Assessments can only be billed per calendar day.
The recommended maximum billable time for psychological testing is eight hours (8.0 units) over a 30-day period. Time spent for the interpretation of testing results without the student present is billable time. Providers must submit documentation of the reasons for the additional time, if more than the recommended maximum time is billed.

Texas Medicaid & Healthcare Partnership
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