Internal Medicine Coding Alert
Mini-Mental Status Exam
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Answer: No. Code 96115 (neurobehavioral status exam [clinical assessment of thinking, reasoning and judgment, e.g., acquired knowledge, attention, memory, visual spatial abilities, language functions, planning] with interpretation and report, per hour) is not the correct way to code a mini-mental status examination. The mini-mental status exam (also known as the Folstein Mini-Mental State) is a brief mental status examination consisting of 11 categories with 30 components. One point is assigned for each correct answer. A perfect score on the examination is 30. Any score under 20 is considered abnormal, any score between 21-25 is considered equivocal, and any score of 25 or more is considered normal. While the mini-mental status exam does assess some of the items listed in the CPT description of the neurobehavioral exam, namely attention, memory, visual-spatial abilities and language functions, it does not address all of them. When coding, it is always important to read every word in the description. Note that the description for 96115 also states with interpretation and report, per hour. The mini-mental status exam does not normally take a full hour nor is a formal report created. The examiner simply scores the 30 components and reports a score.
According to CPT Assistant, the mini-mental status exam takes less than 15 minutes to perform and interpret and is not the type of detailed testing that code 96115 was intended to report. A mini-mental exam is coded as part of the examination of an E/M and will contribute to the level of service selected.
Answers for You Be the Coder and Reader Questions were reviewed by Kathy Pride, CPC, coding supervisor for the Martin Memorial Medical Group, a 57-physician group practice in Stuart, Fla.
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