Internal Medicine Coding Alert

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

According to CPT Assistant, to bill for 96115 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 method-ology, 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. Getting paid separately for a mini-mental status exam is one of the most common myths in coding folklore, says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C. A clue in the code definition for 96115 is that it should be reported per hour.

Therefore, brief mental status exams such as the MMSE should be included in whatever E/M service (99211-99215) is performed during that visit.