Internal Medicine Coding Alert

Question: What is the correct way to bill for a mini-mental status examination (MMSE)? A neurobehavioral status exam (96116) is billed in one-hour units, which is longer than we take for an MMSE, but it is the only code that seems appropriate.


South Dakota Subscriber

Answer: Carriers do not believe that the work involved with or the time spent on an MMSE is sufficient to meet the requirements for billing 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).

According to CPT Assistant, to bill for 96116 the physician must perform a clinical evaluation of memory, attention/concentration, motor speed and strength, speed of mental processing, language functions, visual-spatial abilities, planning and judgment, etc. The evaluation should also include hypothesis-testing Lurian methodology, expanded mental status Milestone Screen, with interpretation and interview, and selected items from formal psychological tests. The physician then interprets the findings, formulates a diagnostic impression and recommends treatment.

By comparison, a physician performing an MMSE, which is a quick way to evaluate cognitive function and screen for dementia or monitor its progression, does not do all of the work described above. Therefore, brief mental status exams such as the MMSE should be included in whichever E/M service (99211-99215) the internist performs during that visit.

Answers to You Be the Coder and Reader Questions were reviewed by Kathy Pride, CPC, CCS-P, director of consulting and training for QuadraMed in Reston, Va.; and Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for Rachlin, Cohen & Holtz LLP, a Fort Lauderdale, Fla.-based accounting firm with healthcare expertise.