Internal Medicine Coding Alert

Question: I have a physician who wants to bill for a Mini Mental Status Exam (MMSE). Can we bill 96116 for this service?

California Subscriber

Answer: No, it is not appropriate to code 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 psychologists or physicians time, both face-to-face time with the patient and time interpreting test results and preparing the report) for the Mini Mental Status Exam (MMSE).

An MMSE can be part of neurobehavioral testing,though a mini mental status exam by itself is not reportable using 96116, according to the American Academy of Neurology. When performed without additional neurobehavioral testing, consider an MMSE part of the E/M service.

When the MMSE is done as part of more extensive neurobehavioral testing as described above, you may report 96116. In 2006, the AMA created 96116 to report the neurobehavioral status examination by a  psychologist or psychiatrist, with subsequent interpretation and report.Code 96116 describes gathering information to provide an important first analysis of brain dysfunction, and the progression and changes in the symptoms over time.