Neurology & Pain Management Coding Alert

Check the time and components to accurately code neurobehavioral testing.

When you're coding neurobehavioral or neuropsychiatric testing, you'll need to know when these services are included in E/M and when they're separately reportable. The guidance below should help you steer the right course toward full earned pay for these non-invasive tests.

The basics: The descriptor for code 96116 (Neurobehavioral status exam [clinical assessment of thinking, reasoning and judgment, e.g., acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities], per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report) clearly indicates that there should be a record of the face-to-face interaction of the physician and the patient. You need to ensure that you have this adequately documented.

MMSE? Not so fast: You do not use 96116 to report a mini-mental status exam (MMSE). MMSE may take only 10-15 minutes of physician time to perform and interpret. An MMSE can be a part of neurobehavioral testing, but you cannot report an MMSE exclusively by using 96116.

If you see that your neurologist has done an MMSE without any additional neurobehavioral testing, you report the MMSE with an appropriate E/M code. When your neurologist does the MMSE as part of more extensive neurobehavioral testing, you can report 96116.

"The MMSE is a quick 30-point validated questionnaire to screen for cognitive impairment. It briefly measures such parameters as orientation to time and place, immediate recall, calculation and language. It is often used to screen for dementia or monitor its progression," says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, Co.

"The code 96116 is intended to describe the performance of gathering information to provide an important first analysis of brain dysfunction and the progression and changes in symptoms over time," says Hammer. "The neurologist often will first conduct a clinical assessment via an interview with the patient and significant others, if applicable. This assessment helps determine the types of tests and how those tests should be administered. If the documentation supports not only the patient interview and performance of the MMSE, but also additional screening for impairments in acquired knowledge, attention, language, learning, memory, problem-solving and visual-spatial abilities, you can likely report code 96116."

If a reimbursable test was separately performed, your neurologist's notes must indicate it. If you fail to find documented support for the neurological testing, you are only left with the option of reporting the E/M service alone with a code from 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient ...) for a new patient visit or 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) for an established patient.

Record Testing, Face-to-Face Time

Hammer states, "Appropriately billing for the neurobehavioral status exam is solely dependent upon time." Note the CPT® code description for 96116 includes "...per hour of the psychologist's or physician's time...." Make sure your neurologist or psychologist records the total time spent in not only his face-to-face time performing the assessment but also the time it took to administer and score the tests and likewise generate the report of his findings.

Tip: To report 96116, you need to report time for both face-to-face time with the patient and time interpreting test results and preparing the report. According to CPT®, you will need to confirm that your neurologist spent a minimum of 31 minutes for the patient assessment to be able to report the one hour specification in 96116.

Example: If you read that your neurologist administered a short series of questions to the patient which consisted of questions which aimed at testing the orientation (date and time of the day), memory (birthday and anniversary), executive functional testing (asking the patient if he can dress himself), visuospatial abilities (shows objects in garden from the window and asks the patient to describe how these are related), and finishes the exam in about 40 minutes, you report 96116 as the testing is confirmative for neurobehavioral examination is performed for a duration that is more than 31 minutes.

Establish Separate E/M Service with 96116

You can report an E/M service with 96116. To do this, make sure that the neurobehavioral status exam is separate and distinct from the key components of the E/M service. Code 96116 is bundled as a column 2 component of most E/M service codes. Hammer states, "However, if your provider's documentation supports that the neurobehavioral exam was separate and distinct from the E/M service, the National Correct Coding Initiative (NCCI) allows a modifier, such as 59 (Distinct procedural service) to be appended the 96116 code to bypass the NCCI bundling edit." The modifier specifies that your neurologist did the additional work.

You will need to specifically look for distinct neurobehavioral examination in the clinical note. Hammer shares an example, "A 68-year-old established patient, is seen by the neurologist for management of her previously diagnosed cauda equina syndrome. The physician performs his normal history and physical exam of the patient and decides to change the patient's prescriptions to better manage the chronic cauda equina syndrome." Reading further, you will confirm the neurobehavioral examination. "At the visit, the patient's daughter also reports changes in her behavior, including attention difficulties, memory problems, and difficulties with problem solving. The neurologist performs a neurobehavioral status exam in order to establish a medical diagnosis for the patient's new symptoms." In this case, you report 96116 along with modifier 59.