Neurology & Pain Management Coding Alert

Question: Does a neurobehavioral status exam fall under E/M service, or can we code it independently?

Montana Subscriber

Answer: The CPT code for neurobehavioral status exam is 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). But make sure your physician meets all the code's criteria before you submit it.

If your physician's exam is not extensive enough to meet all those criteria, you-ll report an E/M service instead. Look to 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient ...) for a new patient visit or 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) for an established patient.