J.  PSYCHOLOGICAL SERVICES – ASSESSMENT SERVICES

J1. Define and describe assessment services (Psychological Services – Procedure Code 96101) under the SHARS program.

Assessments are activities performed for the purpose of determining eligibility for special education including:

  • An initial assessment that leads to the creation of an Individualized Education Program (IEP)
  • An assessment for a student that has an existing IEP and is referred for assessment for a different disability, whether or not that assessment leads to a revised IEP
  • An assessment that leads to a dismissal from special education

Billable time includes direct testing time with the student, interpreting results when the student is not present, and report writing time when the student is not present. Parent consultation (student present) required during the assessment due to a student’s inability to communicate or perform certain required testing activities is also billable as direct testing time. Assessments are billable under procedure code 96101.

J2. Can assessments performed by an educational diagnostician be billed under the SHARS program?

No, assessments billed under the SHARS program cannot be performed by an educational diagnostician. Assessments must be performed by a Licensed Specialist in School Psychology (LSSP), a licensed psychologist or a psychiatrist.

NOTE: Effective 9/1/06 educational diagnosticians were eliminated as approved SHARS providers. HHSC attempted to present an argument to CMS to reinstate educational diagnosticians through SPA 06-028. CMS denied SPA 06-028 in November 2007.

J3. Are initial assessments that don’t lead to the creation of an IEP billable?

An initial (psychological) 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 under 21 years of age, whether or not the IEP includes SHARS. So, if an initial assessment does not lead to the creation of an IEP, that assessment is not billable under SHARS.

J4. Are testing, interpretation, and report writing billable under assessments?

Yes, testing, interpretation, and report writing is billable under assessments as long as the initial (psychological) assessment resulted in the creation of an IEP.

Procedure code 96101 is the only code that is billable for times when the client is not present (e.g., interpretation time and report writing time). See also response to J2.

J5. May writing the assessment report (96101) be billed separately from the assessment?

Yes. An assessment involves direct testing, interpretation, and report writing. Writing the report may occur on a different day than the direct testing. Each activity should be billed on the day it occurred. Documentation must include date, start time, stop time, and a notation as to which activity (i.e., direct testing, interpretation, or report writing) was done.

J6. Does the report writing time include writing the IEP?

No, writing the IEP is not a billable component of assessments.

J7. Must testing time, interpretation and report writing be done during school hours?

No, if the service is performed and properly documented the services are billable regardless of when they were done.

J8. Assessment reports are sometimes written during the ARD meeting. Is this time billable?

Yes, the clinician may bill for report writing during the ARD; however, the ARD meeting itself is not a billable service. See also response to J7.

J9. May assessments for students with visual impairments be billed?

No, visual impairment assessments and visual screenings are not billable SHARS services.

J10. Are autism evaluations a covered SHARS benefit?

Autism evaluations are not reimbursable through the SHARS program. Autism screening is covered by Medicaid benefits when billed by Texas Health Steps providers.

For further information please visit their website at http://www.txhealthsteps.com/cms/

J11. Are any pre-ARD/ARD meetings billable?

Assessment write-ups (i.e., analyzing the data or writing the report) during the ARD meeting is billable. Pre-ARD meetings are not billable because there is no SHARS service being provided to the student.

J12. What are the guidelines for billing reevaluations?

Referrals are generally good for 3 years. This is based on the 3 year revaluation time required by school districts under IDEA. According to IDEA, the re-evaluation can occur more frequently than the 3-year evaluation timeline, see below:

A reevaluation conducted under 34 CFR 300.303(a):

  • May occur not more than once a year, unless the parent and the public agency agree otherwise; and
  • Must occur at least once every 3 years, unless the parent and the public agency agree that a reevaluation is unnecessary.