Neurosurgery Coding Alert

 Question: What is the proper code to report a mini-mental exam? I've heard that we should use 96115, but this doesn't seem correct when I read the code descriptor.

Kentucky Subscriber

 Answer: Reporting 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) for a so-called "mini" mental exam is a common mistake.

A mental status examination as described by 96115 involves a lengthy neurobehavioral status examination lasting an hour or more, and could include a full evaluation of digit span, a four-item similarities task, a 15-item naming task, a 10-word learning test with recall and recognition, four drawing items and a word-list generation task, as well as other tests.

The mini-mental status exam, in contrast, is a superficial, 15-minute test "never meant to substitute for more comprehensive testing," according to CPT Assistant (October 2000).

You cannot separately report a mini-mental exam. Rather, if documentation describes an exam of 30 minutes or less, Medicare considers the service to be part of any associated consultation, clinical interview or E/M service that the surgeon provides. Therefore, you must include the exam as a part of any E/M service you report.