Primary Care Coding Alert

Question: An FP saw a 72-year-old woman because she had been feeling light-headed and dizzy. The woman's adult daughter also came to the appointment and expressed concern about her mother's condition. The daughter noted that the mother's personal habits and hygiene were deteriorating rapidly, and that she frequently failed to recognize friends and acquaintances.

During the office appointment, the doctor evaluated the woman's symptoms of dizziness (780.4), checked her blood pressure, which was being controlled by medication (401.1, Essential hypertension, benign), and conducted a mini-mental status examination (MMSE).

Florida Subscriber

Answer: For an MMSE, you should assign the appropriate level office visit code (99212-99215, Office or other outpatient visit ...). The AMA, Medicare, and other professional organizations have gone on record to state that mini-mental status exams are included in E/M services and should not be reported separately.

Beware: If you are being paid with an alternate code, this is a serious mistake. Some coders, when seeing the physician's note about performing an MMSE, assign 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). This code, however, is classified as a psychological testing code and describes a specific test that is administered to determine neurobehavioral status. The neurobehavioral testing tool described in 96116 is longer and more detailed than the mini-mental status exam, generally taking about one hour to complete and requiring extensive evaluation.