Neurology & Pain Management Coding Alert

Question: How often should neurologists repeat a mini mental status exam (96115) in their Alzheimers patients?

Anonymous Georgia Subscriber

Answer: Mini mental status exams are considered part of the neurologists evaluation and management (E/M) service and would not be assigned 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). Generally, a mini medical exam of an Alzheimers patient involves the same level of questioning that a physician uses during an E/M visit. Therefore, it is not appropriate to bill for additional effort or time. The mini mental exam should be reported with the E/M code that most accurately describes the level of detail involved:

- Level I 99231 most often is assigned for routine care of patients.

- Level II99232represents a more detailed level of care.

- Level III99233describes a complex examination.

Code 96115 is not an appropriate code to assign because it describes a detailed evaluation of how well a patient is functioning both neurologically and psychologically.