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A psychological testing administration note documents a test administration and scoring encounter: which standardized instruments were given, who administered each one (psychologist or technician), and the total face-to-face minutes supporting each billed unit of CPT 96136 to 96139. Psychologists, neuropsychologists, and testing technicians write one for every administration session. Most notes run 150 to 350 words plus the time log.
The administering psychologist, or a trained testing technician (psychometrist) with the supervising psychologist accountable
The supervising and interpreting psychologist, Medicare and commercial payers, auditors, state boards
150 to 350 words plus the time log · 4 to 10 minutes by hand (clinical team estimate)
Structured diagnostic-test encounter record (compare: psychological evaluation report, outcome measure note)
Every test administration and scoring session billed under 96136 to 96139, including each day of a multi-day battery
The ordering and supervision framework is law; the contents are payer policy; a discrete administration note is convention
A psychological testing administration note documents the administration and scoring leg of psychological or neuropsychological testing: the standardized instruments given, each named; who administered each one; the total face-to-face minutes behind every billed unit; and the supervision under which a technician worked. No professional body ever published an official template, and no author or year can be cited. The document is an emergent byproduct of the 2019 CPT restructuring, effective January 1, 2019, which split administration and scoring into a provider pair (96136, 96137) and a technician pair (96138, 96139), replacing legacy codes such as 96102, layered on Medicare's longstanding diagnostic-test rules. Clinicians and payers also call it a test administration and scoring note, psychometrist note, technician note, test administration log, time log, or start-stop time note; none of those names is official either.
The load-bearing boundary is with the psychological evaluation report. Administration and scoring time lives here; test selection, interpretation, integration, and feedback are the professional work of the evaluation codes 96130 to 96133 and belong in that report. Just as load-bearing: no statute or regulation requires an administration note as a stand-alone document. What the law compels, as a condition of Medicare payment, is the diagnostic-test framework at 42 CFR 410.32: testing ordered by the treating practitioner, furnished under the right level of supervision, with documentation that is legible, signed, and kept in the record. The note is simply the one artifact that proves all of it at once.
Assessment-heavy settings write these daily: neuropsychology and psychological assessment practices, hospital and academic medical centers, rehabilitation units, and any clinic running a technician model. That model is the norm, not the exception: a 2002 practice survey found 51.2 percent of more than 1,300 respondents employed testing technicians, and the field's 2020 practice and salary survey of 1,677 doctoral-level practitioners (Sweet et al., 2020) found reliance on technicians remains popular, especially in institutional and specialty neuropsychology settings, while observing that the 2019 code changes appear to have had "more negative than positive effects" on practice. Write one for every administration and scoring session, whoever administers: the psychologist's own session supports 96136 and 96137, the technician's supports 96138 and 96139. For a single brief symptom questionnaire scored in session, an outcome measure note is the right artifact instead; a full battery earns this note, and the write-up conventions for individual instruments live in guides like our WAIS report guide.
Encounter header and the order. Patient identifiers, date of service, the treating practitioner who ordered testing, and the referral question. Medicare treats psychological and neuropsychological testing as a diagnostic test, so the order and the clinical rationale must exist in the record; this header ties the session to them. Pitfall: an administration note floating free of any order. When the order and medical-necessity rationale are nowhere in the chart, every downstream unit is deniable no matter how clean the time log looks.
Tests administered, by name. List every instrument given that day by full name or standard abbreviation. Payer policy expects the specific tests to be identifiable, and full batteries typically run 4 to 8 hours of testing under the national LCD's own description. Pitfall: "comprehensive battery administered per referral." An auditor cannot match unnamed tests to billed time, and unnamed tests read as tests that may not have happened.
Administrator and role. Say who gave each test and in what role: the psychologist personally, or a trained technician. The entire split between the provider codes and the technician codes turns on this fact, and under Medicare the technician needs no license or certification: "trained technician" is the Benefit Policy Manual's whole requirement, with anything stricter coming from state boards or commercial payers. Name and credential them anyway. Pitfall: a note that never says who ran the tests. With the administrator unstated, neither code pair is supported and the claim rests on nothing.
Supervision statement. Name the supervising psychologist or physician and record the supervision actually delivered. The controlling regulation, 42 CFR 410.32(b)(2)(iii)(B), requires general supervision for these tests, meaning available rather than physically present, while the national LCD says the technician "must be directly supervised." Document availability, and any on-site time, and the conflict resolves in your favor either way. Pitfall: boilerplate claiming on-site direct supervision that the appointment book contradicts. Auditors read this line against the supervisor's schedule.
The time log. Record total face-to-face administration and scoring minutes for each administrator. No CMS authority requires literal start and stop clock times; what is required is total time supporting each 30-minute unit, with an added unit earned 16 minutes past the prior increment. Start-stop notation is defensive practice worth keeping for long batteries. For multi-day testing, combine the time and report it on the last date of service. Pitfall: unit-shaped time. Minutes recorded as exactly 30 per unit, every session, is the first pattern integrity reviewers flag.
Behavioral observations. Effort, engagement, breaks, accommodations, interruptions, and anything bearing on validity. CMS never separately requires them for this note; they are clinical convention, and their real job is protecting the interpretation that will later be built on these scores. Pitfall: the same "cooperative, adequate effort" line copied forward across sessions. Observations that never vary support nothing when validity is later questioned.
Scoring and disposition. Scoring by the person who administered belongs inside these codes, so document it within the total minutes, then route raw results to the interpreting clinician and sign the note; payer policy expects documentation legible and signed. Pitfall: interpretation smuggled into the administration note. Integration and report writing are the evaluation codes' work, and billing that thinking here double-counts it.
PSYCHOLOGICAL TESTING ADMINISTRATION NOTE Administration and scoring encounter (CPT 96136 to 96139). Name every test, say who gave it, and let the minutes support the units. Interpretation belongs in the evaluation report. ENCOUNTER Patient: __________________ DOB: __________ DOS: __________ Ordered by (treating practitioner): _________________________ Order date: __________ Referral question: __________________ TESTS ADMINISTERED TODAY (each instrument by name) 1 ___________________________ 3 ___________________________ 2 ___________________________ 4 ___________________________ Administered by: [ ] psychologist (96136/96137) [ ] trained technician (96138/96139) Administrator name / credentials: ___________________________ SUPERVISION (technician-administered testing) Supervising psychologist or physician: ______________________ Level delivered: [ ] general (available) [ ] on site: ______ Availability documented (how): ______________________________ TIME LOG (face-to-face administration + scoring minutes) Today: start ______ stop ______ breaks ____ total ________ Prior day(s) of this battery: _______________________________ Combined total, reported on last DOS: _______________________ Units supported (30 min, then 16+ past each increment): _____ BEHAVIORAL OBSERVATIONS (effort, breaks, validity-relevant) _____________________________________________________________ _____________________________________________________________ SCORING AND DISPOSITION Scored by: _______________ Scoring minutes (in total): _____ Raw results routed to (interpreting clinician): _____________ Signature / credentials: __________________ Date: __________
Free to use and share, no signup. The PDF includes a one-page cheat sheet with section-by-section pitfalls and a pre-sign checklist; the DOCX is the blank template, ready to adapt.
Scenario: day two of a two-day adult attention and memory battery in an outpatient neuropsychology practice. A trained testing technician administers under the neuropsychologist's general supervision. All details are fictional.
Psychological Testing Administration Note. Cedarbrook Neuropsychology Group · Patient: R.T., 34 · DOS: 07/28/2026 (day 2 of 2) · Technician: M. Alvarez, BA · Supervisor: L. Chen, PhD
Order and referral question: Testing ordered 07/10/2026 by P. Rowan, MD (psychiatry) to clarify adult ADHD versus anxiety-related attention complaints; order and rationale filed with the 07/10/2026 referral. First administration day 07/21/2026.
Tests administered today (by M. Alvarez, trained testing technician): CVLT-3; CPT-3; CAARS 2 self-report and observer ratings; WAIS-5 processing speed subtests carried over from day one. All administered per manual under standard conditions, marking the battery complete.
Supervision: L. Chen, PhD, clinical neuropsychologist, provided general supervision as permitted for diagnostic psychological and neuropsychological tests: available by phone and secure message throughout testing, on site 1:00 to 3:30 pm, and reviewed the session with the technician at 3:15 pm.
Time: Today 1:05 to 3:12 pm with one 10-minute break: 117 face-to-face technician minutes, administration and scoring. Combined with day one (96 minutes on 07/21/2026), total technician time for the battery is 213 minutes, reported today as the last date of service: 96138 for the initial 30-minute unit and 96139 for six added units; a seventh add-on would have needed 226 minutes.
Behavioral observations: Arrived on time wearing corrective lenses. Effort sustained across tasks with mild fatigue late in CPT-3; one scheduled break at 2:10 pm; no interruptions. Responses complete; engagement adequate throughout and consistent with interpretable results.
Scoring and disposition: All day-two instruments scored by M. Alvarez per test manuals within the minutes above; raw and scaled scores entered in the record. Results routed to Dr. Chen for interpretation and integration under the evaluation codes; feedback visit scheduled 08/04/2026. Signed: M. Alvarez, testing technician, 07/28/2026. Supervision acknowledged: L. Chen, PhD, 07/28/2026.
This sample is fictional and for educational purposes. It does not describe a real patient, clinician, or practice.
Writing these after every session? BastionGPT drafts complete notes from bullets, dictation, or a transcript.
Generate a note from bulletsSort the obligations by strength and this note gets much easier. LAW: the diagnostic-test framework at 42 CFR 410.32, ordering by the treating practitioner and supervision by a physician or clinical psychologist. PAYER POLICY: the content, per the national LCD L34646 and its billing article: tests by name, total face-to-face minutes, who administered, medical necessity, documentation legible and signed and available on request. CONVENTION: the discrete, titled administration note itself. Inside that stack sits the field's strangest contradiction: the LCD says a technician "must be directly supervised," while the regulation and CMS's own testing FAQ require only general supervision, which does not demand physical presence. The risk-minimizing posture is to document availability and any on-site time as delivered, and to appeal a supervision denial on the regulation's text. On credentials, Medicare asks only for a trained technician and bills the work under the supervising professional's NPI; state boards regulate delegation separately, and commercial payers write their own rules, some keeping the supervising neuropsychologist much closer to the testing room. Keep the record at least seven years for Medicare; some states and payers run longer.
Time is the audit surface. Total administration and scoring minutes support each 30-minute unit, an added unit is earned 16 minutes past the prior increment, and literal start-stop times are defensive convention rather than mandate. The oft-quoted 31-minute minimum belongs to the per-hour evaluation codes, not these 30-minute codes. Multi-day batteries combine their time onto the last date of service; same-day provider and technician administration is billable together with the right modifier under NCCI edits; and full batteries typically run 4 to 8 hours, with some payers capping combined testing time at 8 hours, as Washington's workers' compensation program does. If you administer by telehealth, watch the calendar: 96136 and 96138 sit on the Medicare telehealth list through December 31, 2026, and continuation depends on the CY2027 fee schedule final rule. The format is a convention; the content is the requirement. Elsewhere the note changes character: psychological testing is largely not publicly insured in Canada or Australia, so the record answers college and privacy-law standards instead. In Ontario, a written supervisory agreement with a psychometrist and supervisor co-signature are college requirements, and Australia has no technician administration item at all. The claim side of the same encounter is its own document: see the claim-support billing note, and for the interpretive product, the neuropsychological report.
The enforcement history here is concrete. In a Justice Department case charged in 2015, two companies billed Medicare more than $25.2 million for psychological testing in Gulf Coast nursing facilities, Medicare paid more than $13.5 million on the claims, and the owners were convicted in January 2017. In Michigan, a psychologist submitted roughly 1,700 false claims for neuropsychological testing and 140 more for psychological testing over three years, including one patient billed for neuropsychological testing 21 times in a single year at 24 hours each; the insurer lost about $5 million, and the January 2020 sentence was 51 months with a forfeiture judgment of $3,163,172.92. Note what the record does not contain: the $580 million improper-payment figure often waved at testing is a psychotherapy number from a May 2023 federal audit, and no published OIG or CERT improper-payment rate isolates the testing code family at all. The BastionGPT Clinical Advisory Board sees the same errors most often in testing administration note reviews:
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Under Medicare, no. The controlling regulation, 42 CFR 410.32(b)(2)(iii)(B), and CMS's own testing FAQ require general supervision for diagnostic psychological and neuropsychological tests: the supervising physician or clinical psychologist must be available, not physically present. The complication is that the national LCD says the technician must be directly supervised, so two CMS-associated texts point in opposite directions. The defensible posture is to document availability and any on-site time, and to appeal a supervision denial by citing the regulation. State boards and commercial payers can be stricter, so check both before staffing an off-site day.
No CMS authority requires literal clock times. What is required is total face-to-face administration and scoring time supporting each billed 30-minute unit, with an added unit earned once you pass 16 minutes beyond the prior increment. Start-stop notation is defensive documentation worth keeping for long batteries, but its absence violates no rule. A related confusion: the 31-minute minimum quoted in payer guidance applies to the per-hour evaluation codes, not to the 30-minute administration codes.
Yes. When the psychologist personally administers some instruments and a technician administers others, both code pairs can be reported for the same day, provided each person's face-to-face time is separately documented in the record. Claim edits require an appropriate modifier, such as 59 or XE, on the same-day combination. The one thing that never works is billing a technician's administration under the provider codes: 96136 and 96137 are for the professional's own time.
Combine the face-to-face time and report it on the last date of service; that is the Medicare convention for multi-day testing, and the sample above shows the arithmetic. Full batteries typically run 4 to 8 hours of testing, so long technician days with multiple add-on units are normal, though some payers cap combined provider-plus-technician testing time at 8 hours. Keep each day's minutes in the record even though the claim carries the combined total on the final date.
Under Medicare, none: the Benefit Policy Manual asks only for a trained technician, and the work is billed under the supervising professional's NPI. Anything stricter comes from elsewhere: state psychology boards regulate delegation to unlicensed technicians as a scope-of-practice matter, and commercial payers can impose their own requirements. In Ontario, a written supervisory agreement with the psychometrist is mandatory and the supervisor must co-sign the work, even though psychometrist is not a protected title there.
No US Medicare authority requires a co-signature on the technician's note. Billing already runs under the supervising professional's NPI, and the supervisor's own cognitive work is separately documented under the evaluation codes. Co-signature is a real requirement in Ontario, where the college obliges supervisors to co-sign reports prepared by non-regulated providers. Many US practices co-sign anyway as internal policy, which is sensible risk management rather than federal law, and it is what the sample note models.
Most run 150 to 350 words plus the time log: a header, the test list, the administrator, the supervision line, minutes, brief observations, and disposition. Keep it at least seven years for Medicare, with some states and payers requiring longer. In Australia, psychology records are kept a minimum of seven years from last contact, and for minors until age 25; Canadian colleges set their own retention periods and expect a record of every material service activity, including who administered testing under supervision.
The administration note holds the mechanics: tests by name, who administered each, total minutes, observations, and scoring. The psychological evaluation report or neuropsychological report holds the professional work: test selection, interpretation, integration with history, diagnosis, and recommendations. The regulatory reason to keep them clean is that each defends a different code family in an audit: the note substantiates the administration units, the report substantiates the evaluation codes and medical necessity.
Yes. Give it the day's shorthand: instruments, who administered, minutes, and anything notable about effort or breaks, and it drafts the full note with the supervision statement, the combined multi-day time entry, and the unit arithmetic shown for your review. It can also check a drafted note for the gaps auditors flag: unnamed tests, a missing administrator, or minutes that fail the midpoint math. BastionGPT is HIPAA-compliant with a signed BAA on every plan, and your data is never used to train models.
Educational content, not legal or billing advice. Sample notes are fictional. Follow your organization's policies and your board, payer, and jurisdiction requirements.