Primary Care Coding Alert

Question: May I report a mini-mental status exam (MMSE) with 96115?

Pennsylvania Subscriber

 Answer: No. You should not separately report an MMSE with the psychological testing 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). Instead, include the MMSE in the E/M service the family physician provides.
 
Why: The neurobehavioral testing tool that 96115 describes is longer and more detailed than the mini-mental exam. A full neurobehavioral mental status exam (MSE) generally takes about one hour to complete and requires extensive evaluation. The code's descriptor as a "per hour" code accounts for the test's length. On the other hand, an FP may spend 15 minutes or fewer on an MMSE.
 
Although CPT does not contain a separate code for MMSE, you can often account for the FP's testing in any E/M services the FP also provides. If the MMSE contributes significantly to the exam, history and medical decision-making elements, you may report a higher-level E/M service. In particular, an MMSE may raise the "exam" portion of the E/M service by adding to the number of bullet points (1997 documentation guidelines) or organ systems (1995 documentation guidelines) the physician covers during the exam.
 
Alternative: If counseling and coordination of care consume more than 50 percent of the visit, you may use time as the determining factor when assigning the E/M level. When reporting time-based E/M services, carefully document the time spent face-to-face in counseling and/or coordinating care with the patient or family.