Neurology & Pain Management Coding Alert

CPT^® code 96020 (Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional [i.e., psychologist], with review of test results and report) includes the preservice, intraservice, and postservice work for the neurofunctional testing. Your neurologist will typically perform the following:

·         Before the procedure, your neurologist will review the patient’s records and determine the neurological functions to be mapped.

·         Your neurologist will conduct a brief focused interview followed by the required cognitive/neurologic examination and finalize the battery of tests to be administered during the fMRI (functional MRI). During the fMRI, six functional tests are administered after the initial structural sequences are obtained. The patient is given instructions and help needed to go through the tests.

·         After the fMRI session, a report is generated that explains the neurologic and cognitive functioning.

Documentation signals: Before you report code 96020, you confirm the administration, adaptation, monitoring, scoring, interpretation, and report generation for the tests. Ensure your neurologist keeps documentation for the following:

·         Assessment of baseline performance of the patient before the procedure

·         Cognitive/neurophysiologic tests administered

·         Length of time for each test administered

·         Instructions, stimuli, and responses for the tests administered

·         Changes, if any, made in the test procedures and rationale for the change

·         Imaging sequences obtained

·         Interpretation of test performance