Primary Care Coding Alert

Question: We had a 78-year-old patient present with dizziness. The patient's son accompanied him to the visit and informed the physician that his father was having trouble recognizing friends and family and that his hygiene habits were deteriorating. After evaluating the patient's symptoms, the doctor conducted a mini-mental status examination (MMSE). What code should we use for the MMSE? Florida Subscriber Answer: The MMSE is included in the E/M service. In this case, you can only use an E/M office visit code (99201-99215), but you can factor in the MMSE when determining the level.

Usually the family physician conducts an MMSE on patients with symptoms of early-stage memory loss or poor cognitive functioning. It helps the physician to diagnosis dementia, such as Alzheimer's disease. The exam consists of 10-15 minutes of basic questions to determine the patient's mental status.

Some coders make the mistake of using 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 the MMSE. But this code is for a specific psychological test that determines the patient's neurobehavioral status. Although this code and 96100-96117 (Central nervous system assessments/tests [e.g., neuro-cognitive, mental status, speech testing]) may be reimbursed by some payers for reporting an MMSE, they are incorrect for this purpose.