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.