Neurology & Pain Management Coding Alert

Although CPT includes a specific code for mental status examinations (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), in most cases the service rendered does not meet the requirements to report this procedure. Knowing the difference between a proper mental status exam and a mini-mental exam will prevent fraud accusations and improve coding accuracy.

Usually when physicians document a mental status exam, they are actually performing a so-called mini-mental status exam, or MMSE. As noted in CPT Assistant, Volume 10, Issue 10 (October 2000), "The MMSE is a 30-element examination, originally created to provide a very quick and simple summary test, which could be standardized and used with minimal time required. In general, the MMSE takes less than 15 minutes to perform and interpret. It was never meant to substitute for more comprehensive testing."

Physicians administer the exam which can be a valuable diagnostic tool for stroke victims, Parkinson's patients and others to test a patient's mental acumen and awareness. "The doctor will test the patient's deductive reasoning skills, ask general questions such as the current date and have the patient perform some basic math computations," says Helen Wilson, CPC, medical coder and primary-care physician liaison for Cochise Health Alliance, a 31-physician multispecialty medical group in Sierra Vista, Ariz. Or, the physicians may use a slightly longer standardized testing tool, which takes up to 30 minutes to perform and interpret.

In contrast to an MMSE, CPT Assistant notes, "The testing described by 96115 involves a lengthy neurobehavioral status examination lasting about one hour. This would include detailed evaluation of the patient's thinking, reasoning and judgment (e.g., acquired knowledge, attention, memory, visual spatial abilities, language function and planning) at a level substantially more detailed than in the comparatively superficial MMSE." In particular, additional testing might include a full evaluation of digit span, a four-item similarities task, a 15-item naming task, a 10-word learning test with recall and recognition, four drawing items and a word-list generation task, as well as other tests "as indicated clinically by the particular signs and symptoms of that patient."

Coders searching for a CPT code for MMSE will do so in vain. "The code doesn't exist," says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Systems Inc., which supports family practice physicians in Broomfield, Colo. Rather, if documentation describes only a cursory exam of 30 minutes or less, Medicare considers the testing part of any associated consultation, clinical interview or E/M service and will not pay it as a separate, reimbursable service, she says.

Although you may consider the MMSE when selecting an E/M code, it does not automatically raise the E/M service level. E/M levels must be chosen according to the three components of exam, history and medical decision-making. Only if the MMSE contributes significantly to these components may you report a higher-level E/M service. Specifically, Page sees MMSEs as part of the physical-exam section of the E/M. "Instead of examining the 'physical' body, the provider is examining the 'mental' status of the patient," she says.

Alternatively, if counseling and coordination of care consume more than 50 percent of the visit, you may use time as the determining factor when assigning an E/M service level. For instance, if, after undergoing an MMSE, an established patient discusses his or her condition with the physician for 45 minutes of a one-hour visit, you may code 99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) based on time alone. When reporting E/M services based on time, maintain careful documentation outlining the time spent face-to-face in counseling or coordinating care with the patient or his or her family.

Page strongly advises against reporting 96115 for an MMSE, even if insurers have reimbursed in the past. "It's true that some payers will pay claims like this, but that often occurs because the payers assume that the codes submitted represent the work performed. That is not the case here," she says. Many insurers don't review documentation before they process claims, so they pay for what they believe to be reimbursable services. "If these codes are inappropriately assigned and the practice is audited, all of the reimbursement would have to be refunded," Page warns. If you knowingly commit fraud by billing 96115 for an MMSE, you could be subject to fraud and abuse penalties by the U.S. Office of Inspector General (OIG).

Contact your insurers immediately if you have been billing MMSEs incorrectly. If you come forth, the insurer will work with you to correct the problem. You will have to return some payment, but it's better than the alternative.

If the physician performs a true neurobehavioral exam as described by 96115, he or she must document the test in full, noting the additional time spent above and beyond that involved in any accompanying E/M service. This latter point is especially important because 96115 is a time-based code. Presumably, a physician could spend two to three hours performing a complete mental status exam, in which case you could appropriately report multiple units of 96115. Without proper documentation, however, the claim would stand little chance of prompting reimbursement.

Most often, the physician will provide a mental status exam with an E/M service, such as an office visit or consult. To ensure reimbursement for both services, append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.

To support medical necessity for the mental status exam, report all relevant signs and symptoms, such as delirium (290.41), dizziness (780.4), slurred speech (784.5) or others, as well as any potentially relevant existing diagnoses, such as stroke (436) or Parkinson's (332.0). The diagnoses linked to the E/M service may be the same as those linked to the exam (such as when the specific symptoms prompting the E/M lead to the decision to perform the exam) or different, e.g., an elderly diabetic patient presents for neuropathy but also exhibits symptoms that prompt the mental status exam.