Psychiatry Coding & Reimbursement Alert

Hint: MMSE is a component of neurobehavioral examinations.

When reporting a neurobehavioral status exam, you will need to know the components of the service while being aware of which other psychiatry services you can or cannot report with this examination code.

The basics: You report 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) when your psychologist or neuropsychologist performs a neurobehavioral status examination.

To report the code, your clinician will first conduct a clinical assessment via an interview with the patient and significant others, if applicable. This assessment helps determine the types of tests and how those tests should be administered. Your clinician will not only perform the patient interview, he will also perform a mini-mental status examination (MMSE) and also additional screening for impairments in acquired knowledge, attention, language, learning, memory, problem-solving, and visual-spatial abilities.

Base 96116 Reporting on More than Just Face-to-Face Time

The descriptor for code 96116 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. Since billing is based on time, make sure that your psychologist or neuropsychologist records the total time spent in not only his face-to-face time performing the assessment but also the time it took to administer and score the tests and likewise generate the report of his findings.

Tip: To report 96116, you need to report time for both face-to-face time with the patient and time interpreting test results and preparing the report. According to CPT®, you will need to confirm that your psychologist spent a minimum of 31 minutes for the patient assessment, interpretation, and report to be able to report the one hour specification in 96116. Thus, the first unit of code 96116 covers 31 to 90 minutes of such testing. At 91 minutes, you can report a second unit of the code. “Under general CPT® time rules, you may report a unit of a time-based code when the midpoint of the time indicated in the code descriptor has been passed,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “Since the descriptor for 96116 says ‘per hour,’ you attained one unit when 31 minutes have elapsed, because that is more than midway between zero and sixty minutes. You attain a second hour when a total of 91 minutes have elapsed. If the time involved was 30 minutes or less, you cannot report the code, because the midpoint of the time indicated was not been passed,” Moore adds.

Example: You read that your psychologist administered a short series of questions to the patient that was aimed at testing the orientation (date and time of the day), memory (birthday and anniversary), executive functional testing (asking the patient if he can dress himself), visuospatial abilities (shows objects in garden from the window and asks the patient to describe how these are related) and that he finished the exam in about 40 minutes. He then interpreted and prepared the report. This task took another 40 minutes. You report only one unit of 96116 as the testing and the interpretation took a total of 80 minutes.

Thinking of 96116 For Reporting MMSE? Not So Fast

If your clinician only performs a mini mental status examination (MMSE), you will not be allowed to report 96116 for this service. An MMSE can be a part of neurobehavioral testing, but you cannot report an MMSE exclusively by using 96116. 

The MMSE is a quick, 30-point, validated questionnaire to screen for cognitive impairment. It briefly measures such parameters as orientation to time and place, immediate recall, calculation, and language. It is often used to screen for dementia or monitor its progression. An MMSE typically takes only 10-15 minutes of physician time to perform and interpret.

If you see that your psychologist or neuropsychologist has done an MMSE without any additional neurobehavioral testing, you report the encounter with an appropriate E/M code. When your psychologist performs the MMSE as part of more extensive neurobehavioral testing, you can report 96116, assuming the documentation supports the more extensive testing and that the time involved meets the threshold for reporting this code.

“CPT® guidance is very clear on this point. The time incurred for the physician administration, interpretation and written report associated with the MMSE is included in an appropriate level E/M service code for that patient encounter.It is not meant to substitute for more comprehensive testing, and by itself, it cannot justify reporting 96116,” Moore observes.

Check CCI When Reporting 96116 With Other Psychiatry Codes

If you are looking at reporting 96116 with a psychiatric diagnostic evaluation code (90791 or 90792), you will run into edit bundles. Correct Coding Initiative (CCI) edits bundle 96116 into 90791 and 90792 with the modifier indicator ‘0,’ which means that you cannot report 96116 in addition to psychiatric diagnostic evaluation codes for the same patient on the same date under any circumstances. You cannot overcome the edit using any modifiers.

You will also run into CCI edit bundling if you are trying to report 96116 along with psychotherapy codes. However, the modifier indicator for these edits is ‘1,’ which means you can overcome the edit using a suitable modifier. You will need to append the modifier to 96116. The most likely modifier that you can use with 96116 is 59 (Distinct procedural service) or XE (Separate encounter).

Establish Separate E/M Service with 96116

You can report an E/M service along with 96116. To do this, make sure that the neurobehavioral status exam is separate and distinct from the key components of the E/M service. According to CCI edits, code 96116 is bundled as a column 2 component of most E/M service codes. However, the modifier indicator is ‘1,’ which means that the edit can be overcome with an appropriate modifier in the right circumstances. 

If your provider’s documentation supports that the neurobehavioral exam was separate and distinct from the E/M service, you are allowed to use a modifier, such as 59 or XE, to be appended to 96116 to bypass the CCI bundling edit.