Primary Care Coding Alert

Family physicians and coding professionals are frustrated with the confusion surrounding proper reporting of brief mental assessments often performed in an office setting. The evaluation in question is often noted on the patient chart as a mini-mental exam or mini-mental status examination (MMSE).

The reason that this code cant be found is that it doesnt exist, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Systems Inc., which supports family practice physicians in Broomfield, Colo. When these assessments are conducted by a family physician in his or her office, it is included as part of the evaluation and management (E/M) service. Of course, the performance of a mini-mental exam should be factored in when the appropriate level of E/M code is determined.

Aging Demographics Increase Need for Mini-mentals

Family physicians will often perform a mini-mental exam when a patient presents with symptoms indicative of dementia, early-stage Alzheimers disease or similar conditions.

The physician will spend 10 or 15 minutes asking simple questions to ascertain the patients mental status. The doctor will test the patients deductive reasoning skills, ask general questions like the current date and have the patient perform some basic math computations, explains Helen Wilson, CPC, medical coder and primary care physician liaison for Cochise Health Alliance, a multispecialty medical group of 31 physicians in Sierra Vista, Ariz. Alternately, some physicians use a slightly longer standardized testing tool, which may take 30 minutes to perform and interpret.

Example: A 72-year-old woman is seen by her long-time physician because she has been feeling light-headed and dizzy. The womans adult daughter accompanies her mother to the appointment and takes the physician aside to express concern about her mothers condition. The daughter notes that the mothers personal habits and hygiene are deteriorating rapidly, and that she frequently fails to recognize friends and acquaintances.

During the appointment, the doctor evaluates the womans symptoms of dizziness (780.4), checks her blood pressure, which is being controlled by medication (401.1, essential hypertension, benign), and although the woman angrily protests conducts an MMSE. In this case, office visit code 99214 would be assigned to reflect the detailed history and exam conducted, as well as the moderately complex medical decision-making inherent in this level of care.

Neurobehavioral Codes Are Being Misused

Some coders, when seeing the physicians note about performing an MMSE, assign 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). This code, however, is classified as a psychological testing code and describes a specific test that is administered to determine neurobehavioral status. Coding experts agree that it would be inappropriate to assign 96115 for a mini-mental exam conducted by a primary care physician. The neurobehavioral testing tool described in 96115 is longer and more detailed than the mini-mental exam, generally taking about one hour to complete and requiring extensive evaluation.

Part of the confusion relating to 96115 arose in 1996 when a new subsection, Central Nervous System Assessments/Tests, was added to the CPT manuals Medicine section. At that time, CPT Assistant noted that this subsection was included to promote awareness of these procedure codes (including 96115), because the assessments may be performed by various specialties, including primary care physicians. As a result, some practices erroneously began assigning 96115 whenever they performed a mini-mental exam, instead of using it only to describe the extensive neurobehavioral testing tool.

Related neurobehavioral codes such as 96110 or 96117 may seem appropriate, but are equally incorrect. Most often, these codes are assigned by neurologists or neuropsychologists. They describe a range of services that may include a patient exam and interview, specific tests to assess specific functions, interpretation of the results and a formal report. In addition, assigning psychiatry codes (i.e., 90801, psychiatric diagnostic interview examination) would also be in error.

Use of Alternate Codes Will Not Withstand Audits

Although the AMA, Medicare and other professional organizations have gone on record to state that mini-mental exams are included in E/M services and should not be reported separately, some family practice coders have reported an alternate code and have been reimbursed. Nonetheless, experts agree this is a serious mistake.

There certainly may be cases where a payer has paid a claim like this, Page states. But that may be because the payers assume that the codes submitted represent the work performed but that would not be the case. She adds that payers seldom review documentation in advance of processing a claim and so reimburse what appear to be reasonable services. However, if these codes are inappropriately assigned and the practice is audited, all the reimbursement would have to be paid back. And, in the case of Medicare and other public payers, the practice would be liable for fraud and abuse penalties as well.