Mental Incapacity Evaluation Services

Revised on: January 24, 2019

 

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

For information about this contract, visit the CSD Mental Incapacity Evaluations contract procurement page.

MIE Contractors must enroll in ProviderOne to claim reimbursement for these services. Visit the Health Care Authority’s Provider Enrollment page for additional information.

Medical Evidence Fee Schedule

For a detailed service description of the clinical psychological/psychiatric evaluation, visit the Medical Evidence Requirements and Reimbursements section of the ESA Social Services Manual.

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 a DSHS 13-865 Psychological / Psychiatric Evaluation form or provide a narrative report.  The DSHS 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 complete 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 complete report as described in Exhibit B, Statement of Work

Clinical evaluation

When performed by a licensed/contracted advanced registered nurse practitioner (ARNP) for impairments within their licensed scope of practice

(Taxonomy: 363LP0808X)

$150.00

96150

Modifier U1

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

Clinical evaluation

When performed by a licensed/contracted physician assistant (PA) for impairments within their licensed scope of practice

(Taxonomy: 363A00000X)

$150.00

96150

Modifier U2

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

Missed appointment

  • Client fails to appear at scheduled date and time and the Client or referring Community Services Office (CSO) did not request cancellation within twenty-four (24) hours prior to the appointment

 

  • The Client arrives more than ten (10) minutes after the scheduled start time

 

  • The Contractor observes the Client to be intoxicated

 

  • The Client is threatening or belligerent

 

  • The Client intentionally refuses to cooperate

 

  • The Contractor observes the Client to be in need of emergent medical intervention

$30.00

99199

This is not paid when the Contractor is providing services at a CSO and another Client is available during that appointment time

 

This fee is only paid once per referral

 

When testing is clinically appropriate, MIE Contractors utilize the current version of the following tests in their evaluation (whenever possible). If a Contractor does not have the current version, they notify the DSHS Contact listed on the first page of their MIE Contract to ensure the version is acceptable.

Service Type

Service Description

Reimbursement Fee

ProviderOne Service Code

Additional Conditions

Evaluation of personality disorders

  • MMPI:  Minnesota Multiphasic Personality Inventory1

 

  • PAI:  Personality Assessment Inventory

$50.00

 

 

 

$50.00

 

 

 

96130

Modifier U6

 

 

96130

Modifier U1

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

 

1May substitute the MMPI: Restructured Form provided the report documents why the substitution is necessary

Evaluation of depression

 

  • BDI:  Beck Depression Inventory

 

  • HAM-D:  Hamilton Rating Scale for Depression

 

$10.00

 

 

$10.00

 

96130

Modifier U7

 

96130

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

 

96130

Modifier UB

 

96130

Modifier UC

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

Evaluation of cognitive disorders

  • WAIS:  Wechsler Adult Intelligence Scale

 

  • WMS:  Wechsler Memory Scale

 

  • TONI:  Test of Nonverbal Intelligence2

 

  • TMT:  Trail Making Test Parts A & B

$120.00

 

 

$120.00

 

 

$30.00

 

 

$10.00

96130

Modifier U3

 

 

96130

Modifier U4

 

96130

Modifier UD

 

96130

Modifier U5

2The TONI evaluates 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

96130

Modifier U9

 

96130

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

96130

Modifier UA

 

96136

Modifier U1

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