Part B Insider (Multispecialty) Coding Alert

Question: My question is in regards to CPT^® code 96103 and a hospital site of service. When a provider sees a patient and bills CPT^® 96103 in a hospital-based practice, is there an additional code the hospital bills for the service or do they just bill a higher level E/M code?

Answer: The CPT^® code 96103 (Psychological testing [includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI], administered by a computer, with qualified health care professional interpretation and report) includes both the professional component (i.e. the interpretation and report) and the technical component (i.e. administration of the test) of the service. Further, code 96103 is not a time-based code and is used only once per session regardless of the number of test instruments used or the amount of time involved.

Thus, when the code is billed by a hospital-based practice, there is no additional code that the hospital can bill unless a significant and separately identifiable E/M service was also done, in which case it could be billed in addition to 96103, although modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) would need to be appended to the E/M code to override the CCI edit that otherwise bundles the two services.

Since the practice is “hospital-based,” it is possible that a hospital might bill a facility fee over and above what is paid for 96103 itself. Whether or not the payer would pay the facility fee over and above 96103 would likely depend on the payer and their contract with the practice and hospital.