Mental Incapacity Evaluation Services

Medical Evidence Fee Schedule

Mental Incapacity Evaluation Services

Reimbursement for psychological evaluations and testing is limited to the terms and conditions outlined in the Community Services Division (CSD) Mental Incapacity Evaluation contract. 

For information about contracting with DSHS please visit the CSD Mental Incapacity Evaluations contracts page.

CSD Contractors must be enrolled in ProviderOne to claim reimbursement for these services.  Please visit the Health Care Authority’s New Providers page for information about ProviderOne enrollment.

 

NOTE:  The maximum payment for all evaluation and report services includes the cost of providing chart notes and medical records.  Providers may choose to use DSHS form 13-865 or provide a narrative report.  The psychological evaluation form 13-865 must be typed in order to be eligible for payment.

Service Type

Service Description

Reimbursement Fee

ProviderOne Service Code

Additional Conditions

Clinical Evaluation

When performed by a licensed/contracted psychologist (Taxonomy:  103T00000X)

$150.00

96150

Modifier 25

Must be an acceptable written report as described in Exhibit B, Statement of Work.

Clinical Evaluation

When performed by a licensed/contracted psychiatrist (Taxonomy:  2084P0800X)

$170.00

90791

Must be an acceptable written report as described in Exhibit B, Statement of Work.

Evaluation of general mental disorders

  • MMPI-2:  Minnesota Multiphasic Personality Inventory*

 

  • PAI-II:  Personality Assessment Inventory

 

 

 

$50.00

 

 

 

$50.00

 

 

 

96101

Modifier U6

 

 

96101

Modifier U1

No more than one (1) test from this category per evaluation

 

*May substitute the MMPI-2: Restructured Form provided the report documents why the substitution is necessary.

Evaluation of depression

 

  • BDI-II:  Beck Depression Inventory

 

  • HAM-D:  Hamilton Rating Scale for Depression

 

$10.00

 

 

$10.00

 

96101

Modifier U7

 

96101

Modifier U8

No more than one (1) test from this category per evaluation.

Evaluation of anxiety

  • BAI:  Beck Anxiety Inventory

 

  • HAM-A:  Hamilton Rating Scale for Anxiety

 

$10.00

 

 

$10.00

 

96101

Modifier UB

 

96101

Modifier UC

No more than one (1) test from this category per evaluation.

Evaluation of cognitive disorders

  • WAIS-III or WAIS-IV:  Wechsler Adult Intelligence Scale

 

  • WMS-III:  Wechsler Memory Scale

 

  • Test of Nonverbal Intelligence, Fourth Edition (TONI-4)

 

  • Trails:  Trail Making Test Parts A & B

$120.00

 

 

 

$120.00

 

 

$30.00

 

 

$10.00

96101

Modifier U3

 

 

96118

Modifier U4

 

96101

Modifier U4

 

96118

Modifier U5

The TONI is used to evaluate individuals with limited language ability.  It is reimbursed instead of and not in addition to the WAIS and WMS.

Evaluation of potential memory malingering

  • Rey Fifteen-Item Memory Test

 

  • TOMM:  Test of Memory Malingering

$10.00

 

 

$30.00

96101

Modifier U9

 

96101

Modifier U2

No more than one (1) test from this category per evaluation.

Evaluation of potential psychiatric illness malingering

  • M-Fast:  Miller Forensic Assessment of Symptoms Test

 

  • SIRS:  Structured Interview of Reported Symptoms

$20.00

 

 

$10.00

96101

Modifier UA

 

96101

Modifier U5

No more than one (1) test from this category per evaluation.

Missed appointment

  • DSHS Client fails to appear at scheduled date and time and the DSHS Client or referring CSO did not request cancellation within twenty-four (24) hours prior to the appointment, unless the conditions in the Additional Limitations column apply.

 

  • The DSHS Client arrives more than ten (10) minutes after the scheduled start time unless the conditions in the Additional Limitations column apply.

 

  • The Contractor observes the DSHS Client to be intoxicated.

$30.00

99199

This is not paid when the Contractor is providing services at a CSO and another DSHS Client is available.

 

This fee is only paid once per referral.

This section details Aged, Blind, or Disabled (ABD) program medical evidence reimbursement rates.  For a detailed service descriptions visit the Medical Evidence Reimbursements section of the ESA Social Services Manual.