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Neurology & Pain Management Coding Alert

Coding Tips:

Thinking Of Reporting 96116 With E/M Service? Read This First

Published on Mon Feb 27, 2012

Check the time and components to accurately code neurobehavioral testing.When you're coding neurobehavioral or neuropsychiatric testing, you'll need to know when these services are included in E/M and when they're separately reportable. The guidance below should help you steer the right course toward full earned pay for these non-invasive tests. The basics: The descriptor for 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 psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report) clearly indicates that there should be a record of the face-to-face interaction of the physician and the patient. You need to ensure that you have this adequately documented. MMSE? Not so fast: You do not use 96116 to report a mini-mental status exam (MMSE). MMSE may [...]
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