Neurology & Pain Management Coding Alert

Although CPT includes a specific code for mental status examinations (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), in most cases the service rendered does not meet the requirements to report this procedure. Knowing the difference between a proper mental status exam and a mini-mental exam will prevent fraud accusations and improve coding accuracy. Mental Status Versus Mini-Mental Usually when physicians document a mental status exam, they are actually performing a so-called mini-mental status exam, or MMSE. As noted in CPT Assistant, Volume 10, Issue 10 (October 2000), "The MMSE is a 30-element examination, originally created to provide a very quick and simple summary test, which could be standardized and used with minimal time required. In general, the MMSE takes less than 15 minutes to perform and interpret. It was never meant to substitute for more comprehensive testing."

Physicians administer the exam which can be a valuable diagnostic tool for stroke victims, Parkinson's patients and others to test a patient's mental acumen and awareness. "The doctor will test the patient's deductive reasoning skills, ask general questions such as the current date and have the patient perform some basic math computations," says Helen Wilson, CPC, medical coder and primary-care physician liaison for Cochise Health Alliance, a 31-physician multispecialty medical group in Sierra Vista, Ariz. Or, the physicians may use a slightly longer standardized testing tool, which takes up to 30 minutes to perform and interpret. In contrast to an MMSE, CPT Assistant notes, "The testing described by 96115 involves a lengthy neurobehavioral status examination lasting about one hour. This would include detailed evaluation of the patient's thinking, reasoning and judgment (e.g., acquired knowledge, attention, memory, visual spatial abilities, language function and planning) at a level substantially more detailed than in the comparatively superficial MMSE." In particular, additional testing might include a full evaluation of digit span, a four-item similarities task, a 15-item naming task, a 10-word learning test with recall and recognition, four drawing items and a word-list generation task, as well as other tests "as indicated clinically by the particular signs and symptoms of that patient." MMSE Is Part of E/M Service Coders searching for a CPT code for MMSE will do so in vain. "The code doesn't exist," says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Systems Inc., which supports family practice physicians in Broomfield, Colo. Rather, if documentation describes only a cursory exam of 30 minutes or less, Medicare considers the testing part of any associated consultation, clinical interview or E/M service and will not pay it as a separate, reimbursable service, she says. Although you [...]