CPT Code 96138 Billing Guide

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• 96138

CPT Code 96138 Billing Guide

CPT code 96138 covers psychological or neuropsychological test administration and scoring by a technician, two or more tests, first 30 minutes. Billing guide.

Quick Reference

Code

96138

Code System

CPT

Category

CPT Codes

Published

Jan 30, 2024

Updated

Mar 3, 2026

Reading Time

21 min

CPT® is a registered trademark of the American Medical Association. All CPT code descriptions on this page are paraphrased in original wording; consult the current CPT® codebook published by the AMA for authoritative descriptors.

Understanding CPT Code 96138: Psychological/Neuropsychological Test Administration and Scoring by Technician, First 30 Minutes

In many psychological and neuropsychological evaluation practices, trained technicians — often called psychometrists or psychological testing technicians — perform the hands-on work of administering and scoring standardized tests under the supervision of a qualified health care professional. This delegation model allows the supervising psychologist or other qualified professional to focus their expertise on test selection, interpretation, integration, and report writing, while a trained technician manages the time-intensive administration process. CPT code 96138 captures this technician-administered testing service, covering the first 30 minutes of face-to-face test administration and scoring by the technician.

Introduction

The Bureau of Labor Statistics has noted that the use of psychometrists and testing technicians in psychological evaluation practices has grown alongside the increasing demand for neuropsychological and psychological testing services across healthcare settings. ↗ The technician-administered testing model is widely used across clinical psychology, neuropsychology, forensic psychology, and behavioral health settings, making 96138 one of the most frequently billed codes in the psychological testing code family.

The 2019 restructuring of psychological and neuropsychological testing CPT codes created explicit separate codes for technician-administered testing (96138/ 96139 ) versus professional-administered testing ( 96136 / 96137 ). Before this restructuring, the distinction between who administered the tests was less clearly delineated in the billing code structure, leading to confusion and inconsistent billing practices. The current four-code framework makes the provider-type distinction a central element of code selection, requiring practices to accurately identify and document whether the qualified professional or a technician performed the test administration.

In behavioral health settings, the role of technician-administered testing is particularly important. Behavioral health organizations often serve high volumes of patients requiring standardized assessments for substance use disorders, co-occurring mental health conditions, cognitive screening, and treatment planning. The technician model allows these organizations to provide comprehensive testing services at a scale that would be impractical if the qualified professional had to personally administer every test. However, the lower reimbursement rate for 96138 compared to 96136 reflects the different cost structure and clinical dynamics of technician-administered versus professional-administered testing.

This guide provides psychologists, neuropsychologists, behavioral health administrators, psychometrists, and medical billers with comprehensive guidance on 96138 billing. It covers the code definition, supervision requirements, documentation standards, the critical distinction from 96136, reimbursement considerations, and compliance obligations specific to technician-administered testing.

Understanding the billing and compliance requirements for 96138 is essential for any practice that uses a technician-administered testing model. Incorrect code selection — particularly billing 96136 when a technician actually administered the tests — is one of the most common and consequential billing errors in psychological testing, carrying significant audit and compliance risk.

96138 Overview

CPT code 96138 is defined as: “Psychological or neuropsychological testing administration and scoring by technician, two or more tests, any method, first 30 minutes face-to-face time with the patient/family.”

Purpose and Significance

The purpose of 96138 is to capture the clinical work of test administration and scoring when performed by a trained technician under the supervision of a qualified health care professional. The code recognizes that technician-administered testing is a distinct service from professional-administered testing ( 96136 ), with different cost structures, supervision requirements, and clinical dynamics.

The significance of 96138 in behavioral health and psychological testing is substantial:

• Enables scalable testing services: The technician model allows practices to evaluate more patients because the qualified professional’s time is not consumed by test administration
• Maintains clinical quality: Properly trained technicians can administer standardized tests with the same procedural accuracy as the qualified professional, maintaining the psychometric validity of test results
• Reduces patient costs: The lower reimbursement rate for 96138 compared to 96136 generally translates to lower patient responsibility amounts
• Supports comprehensive evaluations: While a technician administers tests, the qualified professional can review referral information, plan the evaluation, see other patients, or begin interpreting previously completed test data

Quick Facts

The test administration code family:

Key requirements: 96138 requires (1) administration by a technician under qualified professional supervision, (2) two or more standardized tests, and (3) a minimum of 30 minutes of face-to-face time with the patient.

• Code Type: CPT Category I
• Service Category: Psychological/Neuropsychological Test Administration and Scoring
• Billing Unit: First 30 minutes of face-to-face time with the patient
• Coverage: Medicare, Medicaid (varies by state), most commercial payers
• Effective Date: January 1, 2019 (introduced as part of the testing code restructuring)

• 96136 — Test administration and scoring by qualified professional, first 30 minutes
• 96137 — Test administration and scoring by qualified professional, each additional 30 minutes (add-on to 96136 )
• 96138 — Test administration and scoring by technician, first 30 minutes
• 96139 — Test administration and scoring by technician, each additional 30 minutes (add-on to 96138)

Detailed Breakdown

Components and Requirements

To bill 96138 correctly, the following requirements must be met:

Technician administration: The tests must be administered by a trained technician, not by the qualified health care professional. If the qualified professional personally administers the tests, the correct code is 96136, not 96138. The technician may go by various titles depending on the practice and state regulations, including psychometrist, psychological testing technician, psychometrician, testing assistant, or psychology trainee. Regardless of title, the key criterion is that the person administering the tests is not the qualified professional who will interpret the results and write the report.

Supervision by a qualified health care professional: The technician must work under the supervision of a physician or other qualified health care professional (typically a licensed psychologist, neuropsychologist, or psychiatrist). The supervision requirements vary by state law, payer policy, and practice setting. Common supervision models include:

Providers must verify the specific supervision requirements for each payer and each state’s licensing laws.

Two or more tests: As with 96136, at least two distinct standardized tests must be administered during the session billed under 96138. A single test with multiple subtests (e.g., the WAIS-IV) generally counts as one test. The tests must be standardized instruments with established norms and psychometric properties. Examples of combinations meeting the two-test requirement include: MMPI-2-RF + PAI, Trail Making Test + Stroop Color-Word Test, or WAIS-IV + WMS-IV.

Face-to-face time: The 30-minute time frame for 96138 refers to direct, face-to-face test administration and scoring time between the technician and the patient. Time spent by the technician on activities that are not face-to-face with the patient (such as setting up test materials, preparing scoring forms, or consulting with the supervisor) generally does not count toward the 30-minute requirement, although specific payer policies may vary.

Standardized test instruments: The tests administered must be standardized instruments with established psychometric properties. Informal screening tools, unstructured clinical interviews, or non-standardized questionnaires do not qualify for 96138 billing.

Technician training and competency: While the CPT code definition does not specify minimum training requirements for the technician, best practices and many state regulations require that technicians be specifically trained in the standardized administration procedures for each test they administer. The supervising qualified professional is responsible for ensuring the technician’s competency and the integrity of the test administration process. Documenting technician training and competency verification strengthens compliance and supports the quality of the testing service.

Scoring by the technician: The scoring component of 96138 includes the technician’s work in scoring test protocols, whether by hand scoring, using scoring software, or applying scoring rules. Scoring by the technician is bundled into 96138 and should not be billed separately. If the qualified professional performs or reviews the scoring, that activity may be part of the evaluation service ( 96130 / 96131 ) rather than the administration service.

• Direct supervision: The qualified professional must be physically present in the same office suite during test administration, available for immediate consultation. Medicare generally requires direct supervision for incident-to services.
• General supervision: The qualified professional provides oversight and guidance but does not need to be physically present during the testing session. Some states and commercial payers allow general supervision for psychometric testing.
• Personal supervision: The qualified professional must be in the room during testing (rarely required for technician-administered testing but may apply in some training contexts).

Common Pitfalls

• Billing 96136 when a technician actually administered the tests: This is the single most consequential billing error in psychological testing. If a technician — regardless of their training level or the degree of supervision provided — administered the tests, the correct code is 96138, not 96136. Billing 96136 for technician-administered testing misrepresents the nature of the service and creates False Claims Act exposure. The code is determined by who actually sat with the patient and administered the tests, not by who ordered the tests, who supervised the session, or who will interpret the results.
• Failing to meet supervision requirements: If the technician administered tests without the required supervision, the service may not be billable at all. Before billing 96138, verify that the supervision provided meets the applicable state law and payer requirements. Medicare’s incident-to rules generally require direct supervision, meaning the qualified professional must be in the office suite (not necessarily in the room) during the testing session.
• Not documenting the technician’s identity and credentials: The clinical record must clearly identify the technician who administered the tests, including their name, title or credentials, and role. Ambiguous documentation that does not specify whether a professional or technician administered the tests creates audit vulnerability. Records should also identify the supervising qualified professional.
• Billing 96138 for patient self-administered computerized tests: When a patient completes computerized tests independently (such as a computer-administered MMPI-2-RF or computerized cognitive battery where the technician is not actively administering the test), the technician is not performing test administration, and 96138 may not be appropriate. The technician must be actively involved in administering the tests, not merely monitoring a self-administered computerized testing session. Payer policies vary on this distinction.
• Confusing technician-administered testing with testing evaluation services: The technician’s role under 96138 is limited to test administration and scoring. The interpretation, integration, clinical decision-making, and report writing are evaluation services ( 96130 / 96131 ) performed by the qualified professional. Technicians should not be performing evaluation activities, and their time should not be billed under evaluation codes.

Impact on Healthcare System

Impact on Patients

The technician-administered testing model captured by 96138 provides several benefits to patients. Because technician time costs less than the qualified professional’s time, the lower reimbursement rate for 96138 compared to 96136 typically translates to lower out-of-pocket costs for patients through reduced copayments, coinsurance, and deductible application. For patients undergoing comprehensive neuropsychological evaluations that involve multiple hours of test administration, the cost differential between professional and technician administration can be significant.

From a clinical perspective, properly trained technicians provide consistent, standardized test administration. Many psychometrists develop extensive experience in test administration and can maintain strict standardized procedures with high reliability. Patients benefit from the technician’s focus on the administration process while knowing that the qualified professional will bring their clinical expertise to the interpretation and reporting phases.

In behavioral health settings, patients with substance use disorders or co-occurring conditions may undergo testing as part of treatment planning, disability evaluation, or program placement decisions. The availability of technician-administered testing through the 96138 model makes these evaluations more accessible and affordable, which can improve access to appropriate treatment services.

However, patients should be aware that technician-administered testing provides a different clinical experience than professional-administered testing. The technician may not have the clinical expertise to make real-time adaptive decisions during testing (such as selecting supplemental tests based on emerging patterns), and the behavioral observations documented by a technician may be less clinically nuanced than those of the qualified professional. For some patients and some evaluation questions, professional-administered testing ( 96136 / 96137 ) may be clinically preferable.

Impact on Providers

For providers, 96138 represents the economic foundation of the technician-administered testing model. By delegating test administration to technicians, the qualified professional can focus on higher-value activities — test selection, clinical hypothesis formulation, evaluation and interpretation ( 96130 / 96131 ), and report writing — while still generating revenue from the administration services billed under 96138/ 96139.

The financial calculus of the technician model is straightforward: the qualified professional’s time is the practice’s most valuable resource. When the professional administers tests personally (billing 96136 / 96137 ), their time is committed to a single patient for the duration of the testing session. When a technician administers tests (billing 96138/ 96139 ), the professional can simultaneously provide other billable services — clinical evaluations, therapy sessions, or test interpretation for other patients. The professional’s effective hourly revenue is typically higher in the technician model because they are generating revenue from multiple patients concurrently.

However, the technician model requires investment in hiring, training, and supervising testing technicians. Practices must ensure technicians are properly trained on each test they administer, maintain quality assurance processes, and comply with supervision requirements. The cost of technician salaries and benefits, training, and supervision oversight must be weighed against the revenue generated through 96138/ 96139 billing.

Impact on Payers

Payers generally prefer the technician-administered testing model because it costs less — 96138 is reimbursed at a lower rate than 96136. This cost differential reflects the lower labor cost of technician administration and the economic reality that the qualified professional is not directly providing the administration service.

At the same time, payers have a strong interest in ensuring that 96138 is billed only when a technician actually administered the tests and that 96136 is not being billed inappropriately for technician-administered services. Upcoding from 96138 to 96136 — billing the higher-reimbursement professional administration code when a technician actually performed the administration — is one of the most closely monitored billing patterns in psychological testing utilization review.

CMS establishes the RVU values for 96138 in the Medicare Physician Fee Schedule, with lower work RVUs and practice expense RVUs compared to 96136, reflecting the cost differential between technician and professional administration. ↗

Payer controls on 96138 billing include:

• Verification that the rendering provider listed on the claim is the supervising qualified professional, with the technician identified as a supervised individual
• Comparison of 96138 vs. 96136 utilization patterns to identify potential upcoding
• Review of supervision documentation to ensure compliance with incident-to or state-specific requirements
• Prior authorization for comprehensive testing evaluations

Billing Best Practices

Step-by-Step Billing Guide

• Verify supervision requirements before the testing session: Before a technician administers tests, confirm that the supervision arrangement meets the applicable state law and payer requirements. For Medicare, direct supervision (qualified professional in the office suite) is generally required. For commercial payers, verify the specific supervision standard in the provider contract. Document the supervision arrangement in the clinical record.
• Confirm the two-test requirement: Ensure that the technician will administer at least two distinct standardized tests during the session. Plan the test battery in advance with the supervising qualified professional and confirm that the selected tests meet the standardized instrument requirement.
• Track technician face-to-face time accurately: Maintain a time log documenting the start and end times of the technician’s face-to-face test administration and scoring. Clearly note breaks, interruptions, or transitions between tests. If both a technician and the qualified professional administer tests during the same patient encounter, track their times separately.
• Document who administered each test: In the clinical record, explicitly identify the technician who administered the tests by name, title or credentials, and supervisory relationship to the qualified professional. Also identify the supervising qualified professional. This documentation is the primary evidence supporting the use of 96138 and the supervision arrangement.
• Bill 96138 for the first 30 minutes: Submit 96138 for the first 30 minutes of face-to-face test administration and scoring by the technician. If the technician’s administration extends beyond 30 minutes, bill 96139 for each additional 30-minute increment.
• Submit under the supervising professional’s provider number: In most payer arrangements, technician-administered testing is billed under the supervising qualified professional’s National Provider Identifier (NPI). The claim should identify the rendering provider as the qualified professional, with the technician’s role documented in the clinical record. Some payers may have specific requirements for identifying the technician on the claim.

Reimbursement Rates Overview

As of March 2026, reimbursement rates for 96138:

Note: Although 96138 has a lower per-unit reimbursement than 96136, the technician model can generate higher total practice revenue because the qualified professional can provide other billable services simultaneously.

• Medicare: National average reimbursement is approximately $40-$55 per 30-minute unit, based on the Medicare Physician Fee Schedule. This is lower than the 96136 rate (approximately $55-$70), reflecting the lower cost of technician administration. Geographic adjustments via the GPCI apply.
• Medicaid: Rates vary by state, generally ranging from $30-$55 per 30-minute unit. Some states have particular requirements for technician credentialing or supervision that must be met before Medicaid will reimburse 96138.
• Commercial payers: Negotiated rates typically range from $45-$80 per 30-minute unit. As with Medicare, commercial rates for 96138 are generally lower than for 96136, though the differential varies by payer and contract.

Expert Tips

• Standardize technician training and documentation: Develop a formal training program for testing technicians that covers standardized administration procedures for each test in the practice’s battery, behavioral observation and documentation, time-tracking requirements, and the boundaries of the technician’s role. Document training completion and competency verification for each technician and each test they are authorized to administer.
• Implement structured supervision processes: Create a supervision framework that satisfies the most stringent applicable requirements (whether state law, Medicare, or commercial payers). This may include pre-session review of the testing plan, availability during the session for questions or issues, post-session review of test protocols and behavioral observations, and countersignature or attestation on the testing record.
• Maintain clear role boundaries: Ensure technicians understand that their role under 96138 is limited to test administration and scoring. They should not be selecting tests, making clinical interpretations, providing clinical feedback to patients about test results, or performing evaluation activities that belong under 96130 / 96131.
• Track time separately for each provider type: In sessions where both a technician and the qualified professional administer tests, maintain separate time logs for each provider. The technician’s time supports 96138/ 96139 billing, while the professional’s time supports 96136 / 96137 billing. Do not combine or pool these time entries.
• Prepare for payer audits proactively: Given that the 96138 vs. 96136 distinction is a common audit target, maintain audit-ready documentation for every testing session. This includes: technician identity and credentials, supervising professional identity, supervision arrangement, time logs, tests administered by each provider, and behavioral observations. Regular internal audits comparing billed codes to documentation are a best practice.

Compliance and Regulation

Key Laws and Policies

Health Insurance Portability and Accountability Act ( HIPAA ): Technicians who administer tests handle protected health information, including test protocols, patient responses, scoring sheets, and behavioral observation notes. Technicians must be trained on HIPAA requirements and included in the practice’s privacy and security compliance program. Business associate agreements may be required if the technician is not a direct employee of the practice (e.g., independent contractor psychometrists).

False Claims Act (FCA): The most significant False Claims Act risk associated with 96138 is upcoding — billing 96136 when a technician actually administered the tests. This misrepresentation of the provider type who performed the service is a common audit finding and can result in False Claims Act liability, including treble damages and per-claim penalties. Additionally, billing 96138 without the required supervision in place may constitute a false claim because the supervision is a condition of the service being billable.

Mental Health Parity and Addiction Equity Act (MHPAEA): Payer limitations on technician-administered testing — including restrictions on which tests can be technician-administered, session limits, or requirements for professional administration of certain instruments — must comply with MHPAEA parity requirements when testing relates to mental health or substance use disorder treatment. If comparable medical/surgical testing services do not face the same restrictions, a parity violation may exist.

Risks of Non-Compliance

• Recoupment of all claims where 96136 was billed but a technician actually administered the tests (upcoding)
• Recoupment of 96138 claims where required supervision was not provided
• False Claims Act liability for systematic upcoding or billing without supervision
• State licensing board actions against the supervising professional for inadequate supervision
• Professional ethics complaints
• Exclusion from federal healthcare programs for patterns of fraudulent billing
• Loss of payer contracts due to audit findings

10-Point Compliance Checklist

• Verify that the person who administered the tests is accurately reflected in the code billed (96138 for technician, 96136 for qualified professional)
• Document the technician’s full name, credentials, and supervisory relationship for every testing session
• Identify the supervising qualified professional by name and credentials in the testing record
• Confirm that the supervision arrangement meets Medicare, state law, and commercial payer requirements before billing
• Ensure at least two distinct standardized tests were administered before billing 96138
• Maintain face-to-face time logs for the technician’s test administration and scoring
• Verify that the technician is trained and competency-verified on each test they administer
• Ensure the technician’s role is limited to administration and scoring, not interpretation or evaluation
• Conduct regular internal audits comparing billed provider type (96138 vs. 96136 ) to documentation of who administered the tests
• Train all staff — including technicians, billing personnel, and supervising professionals — on the critical distinction between technician and professional administration codes

Future Trends and Updates

Key trends affecting the future of 96138 and technician-administered testing:

• Psychometrist credentialing and certification: The field is moving toward more standardized credentialing for psychometrists and testing technicians. The Board of Certified Psychometrists offers a national certification, and some states are developing specific regulatory frameworks for psychometric technicians. Increased credentialing may affect payer requirements for 96138 billing and could influence reimbursement rates over time.
• Remote supervision of technician-administered testing: Telehealth technology enables the supervising qualified professional to provide real-time oversight of technician-administered testing via videoconference. Some payers and states are developing policies that allow remote direct supervision, which could expand the use of the technician model in settings where the qualified professional is not physically present.
• Growth of testing in behavioral health settings: As behavioral health organizations expand their assessment and testing services — including cognitive screening for substance use disorder patients, trauma-informed assessment batteries, and measurement-based care protocols — the demand for technician-administered testing is expected to grow. SAMHSA has emphasized the importance of comprehensive assessment in behavioral health treatment. ↗
• Technology-assisted test administration: Digital testing platforms that guide technicians through standardized administration procedures, automatically track face-to-face time, and generate scoring outputs are becoming more sophisticated. These tools can improve the consistency and efficiency of technician-administered testing and strengthen the documentation supporting 96138 billing.
• Payer analytics and upcoding detection: Payers continue to refine their data analytics capabilities for identifying practices that may be upcoding from 96138 to 96136. Practices should expect increased scrutiny of their professional-versus-technician administration patterns and maintain documentation that clearly supports their coding decisions.

Conclusion

CPT code 96138 is the foundational billing code for the technician-administered testing model that is widely used across psychological, neuropsychological, and behavioral health evaluation practices. It captures the first 30 minutes of face-to-face test administration and scoring by a trained technician working under the supervision of a qualified health care professional.

For behavioral health providers, correctly using 96138 requires understanding three critical elements: the provider-type distinction (technician vs. professional), the supervision requirements, and the two-or-more-test threshold. The single most important compliance rule is that the code billed must match who actually administered the tests — 96138 for the technician, 96136 for the qualified professional. Practices that maintain clear documentation of the technician’s identity, the supervision arrangement, and the tests administered can bill with confidence and withstand audit scrutiny.

Additional Resources

• Revenue Cycle Management Best Practices for Behavioral Health — Billing workflow optimization
• Compliance Essentials for Behavioral Health Providers — Regulatory framework overview
• Insurance Billing Guides Hub — Complete billing code reference
• Treatment Planning for Behavioral Health — Integrating assessment into care plans

Related Billing Codes

• 96131
• 96136
• 96137
• 96139
• 96156
• 96164

Common questions

Official sources

• The Bureau of Labor Statistics has noted that the use of psychometrists and testing technicians in psychological evaluation practices has grown alongside the increasing demand for neuropsychological and psychological testing services across healthcare settings.bls.gov
• CMS establishes the RVU values for 96138 in the Medicare Physician Fee Schedule, with lower work RVUs and practice expense RVUs compared to 96136, reflecting the cost differential between technician and professional administration.cms.gov
• SAMHSA has emphasized the importance of comprehensive assessment in behavioral health treatment.samhsa.gov