This was a Q&A in the November 2009 CPT Assistant:
Question: For patients being assessed for low back pain, some providers administer and then assess, and may over time follow with tests, such as the Roland-Morris Low Back Pain and Disability Questionnaire, the Oswestry Disability Questionnaire, and similar back or spinal assessment questionnaires. Can these be reported using codes 96101-96125, (Central Nervous System Assessments/Tests [eg, Neuro-Cognitive, Mental Status, Speech Testing])? If not, how should these be reported?
Answer: Tests of this type are not separately reported using codes 96101-96125 or other CPT codes; instead, they are part of the Evaluation and Management (E/M) services provided. The tests are completed by the patient and in the public domain, so there are no additional supply costs and the provider work involved falls within the E/M services (or "evaluation" or "re-evaluation" codes for therapists), as part of the collection of information and assessment of the patient.
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