Neurology & Pain Management Coding Alert

Question: Can we report 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) for mini-mental status exam? 

Ohio Subscriber

 Answer:  Code 96116 is for neurobehavioral testing. Mini-mental status exam (MMSE) can be a part of neurobehavioral testing. You however, cannot report an MMSE exclusively by using 96116.

When to use 96116? You report MMSE with 96116 when your neurologist does the MMSE as a part of more extensive neurobehavioral testing. If additional neurobehavioral testing is not done, you report MMSE with an appropriate E/M code — 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.

To report 96116, make sure your neurologist documents for both face-to-face time with the patient and time spent in interpreting test results and preparing the report. Since 96116 is specific for one hour, you will need to confirm that your neurologist spent a minimum of 31 minutes for the patient assessment.