An Ohio Autism Diagnostic Center Was Billing 96130 Without 96131 Add-Ons. The Missing Code Cost $87,000 in a Single Year.
Table of Contents
THE SITUATION
This diagnostic center conducted full autism evaluations cognitive, adaptive, behavioral, and diagnostic components for children aged 2–12. Evaluations typically ran 6–8 hours of testing across 2 sessions.
Psychologists were billing 96130 (Psychological diagnostic evaluation) as the primary code. In January 2024, the center’s new psychologist asked during onboarding why they weren’t billing 96131.
Nobody in the billing department knew what 96131 was.
WHAT WAS ACTUALLY WRONG
96131 add-on code was never in the billing template:
96131 (Psychological diagnostic evaluation, each additional hour) is the add-on code to 96130. For a 6–8 hour autism evaluation, this code should appear 4–6 additional times alongside the primary 96130. SimplePractice’s default template didn’t include 96131. The billing coordinator had never been trained on the psychological testing code pair. All evaluations had been billed as a single 96130 missing between $1,400 and $2,100 per evaluation in additional reimbursement.
96136/96137 for testing administration also missing:
96136 (Psychological testing evaluation, first hour) and 96137 (additional hours) apply to the standardized testing component of autism evaluations ADOS-2, Vineland, BASC. These were not in the SimplePractice template either. Testing administration was going entirely uncompensated.
No billing coordination between clinical and billing teams on complex evaluations:
Psychologists were completing evaluations and submitting a single-line note for billing. There was no handoff process that communicated the time spent on each component meaning billing had no data to populate add-on codes even if they’d known to use them.
WHAT WE DID
Week 1: Built a psychological testing billing template in SimplePractice 96130, 96131 (auto-calculating based on hours documented), 96136, and 96137 with hour-based units.
Week 2: Created a clinical-to-billing handoff form psychologists document time spent on each evaluation component. Billing pulls directly from the form.
Weeks 3–8: Resubmitted 12 months of completed evaluations with corrected code sets added 96131 and 96136/96137 units based on clinical records documenting time spent.
Ongoing: Monthly billing review of all evaluation claims every 96130 confirmed to have appropriate 96131 add-on units.
THE RESULTS
| Metric | Before | After |
|---|---|---|
| Add-On Code Billing | Never billed | Correctly billed on all evaluations |
| Revenue Recovered | — | $79,000 |
| Revenue Per Evaluation | $680 avg | $2,240 avg |
| Clinical-Billing Handoff | None | Standardized form |
| SimplePractice Template | 1 code | Full testing code set |
WHAT THIS MEANS FOR YOUR PRACTICE
Autism diagnostic billing is one of the most underbilled services in behavioral health—not because the work isn’t done, but because psychological testing code pairs require specific training most teams lack. If your center bills only 96130 on complex evaluations, you’re significantly undercharging for every one.