Psychiatry Coding & Reimbursement Alert

Question: If our psychologist performs neurobehavioral examination and the tests along with the interpretations are done over a period of a few days, should all the tests be collated and reported together on one claim form or should it be reported individually for each separate day? If it has to be collated, what should be the date of service that should be provided?

Chicago Subscriber

Answer: When your psychologist administers a neurobehavioral status examination, you report it with the CPT® code, 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).

As you can see from the descriptor to 96116, it is a time based code that you will report for every hour that your clinician spends in administering the test or in interpreting results of the test and preparing reports. There will be many occasions when your clinician might administer the test on one day and perform the interpretations on another day. Even the examination of the patient might be done on different days.

But, you should not report 96116 breaking it into different units on different calendar dates of service. Instead, you will just have to collate all the units of 96116 based on the number of hours your clinician spent and report it together on one claim form. You will have to use the last date of service as the date on the claim form. If the claims form, such as the CMS 1500 form, provides the opportunity to report a “From” and “To” date for line items, then you capture the range of days over which your psychologist provided 96116 by reporting the first day in the “From” column and the last day in the “To” column.