Neurology & Pain Management Coding Alert

Question: May I code based on time if my neurologist conducts a mini-mental state exam (MMSE)? Virginia Subscriber Answer: The parenthetical note in the 2008 CPT manual under Central Nervous System Assessments/Tests indicates you should look to the E/M codes for a MMSE performed by a physician. The MMSE is a screening tool used to assess cognitive function. It typically takes approximately 10 minutes to complete, and neurologists often use the test by to evaluate patients with possible Alzheimer's disease or another related dementia. Time-based coding: For most E/M services, if your neurologist spends more than 50 percent of the total visit time in counseling and coordination of care with a patient and/or family members, you may use time as the determining factor. CPT defines counseling as a discussion with a patient and/or family concerning one or more of the following areas: - diagnostic results, impressions and/or recommended diagnostic studies [...]