Neurology & Pain Management Coding Alert

The MMSE (mini-mental status exam) is a 30-element examination, originally created to provide a quick and simple summary test, according to CPT Assistant, Volume 10, Issue 10 (October 2000). In general, the MMSE takes less than 15 minutes to perform and interpret, and "was never meant to substitute for more comprehensive testing," CPT Assistant states. Although the MMSE can be a valuable tool to test the mental acumen and awareness of stroke victims, trauma patients and others, CPT does not include a separate code to describe this service.

A full neurobehavioral mental status exam (MSE) (96115) involves a much more extensive evaluation of the patient's thinking, reasoning and judgment, says Anne M. Dunne, RN, MBA, MSCN, administrator for South Shore Neurologic Associates PC in Long Island, N.Y. Such exams include a clinical evaluation of memory, attention, concentration, motor speed and strength, language functions, visual spatial abilities, and reasoning and judgment. Following an MSE, The clinician would interpret the findings, formulate a diagnosis and recommend treatment.