The following is from the Nov 2006 CPT Assistant:
Neurobehavioral Status Exam: 96116
A neurobehavioral status exam is completed prior to the administration of neuropsychological testing. The status exam involves clinical assessment of the patient, collateral interviews (as appropriate), and review of prior records. The interview would involve clinical assessment of several domains including, but not limited to, thinking, reasoning, and judgment (eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities). The clinical assessment would determine the types of tests and how those tests should be administered.
Code 96116
Code 96116, the neurobehavioral status exam, is intended to describe the process of gathering clinical information that is used to assess brain dysfunction and the progression and change in symptoms over time. Code 96116 is reported for the neurobehavioral status examination as given by the physician or psychologist with subsequent interpretation and report by the physician or psychologist. It includes time for interpreting test results and report preparation. However, as the testing related to the neurobehavioral status exam is only done by the physician or psychologist, there are no codes for technician or computer administration. A physical health (vs mental health) diagnosis is associated with this code.
96116Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, eg, 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
Clinical Example: 96116
A 68-year-old woman is referred by her neurologist due to family reports of changes in her behavior, including attention difficulties, memory problems, and difficulties with problem solving. A neurobehavioral status exam is completed for the purpose of making a medical diagnosis.
Description of Procedure (96116)
The physician meets with the patient and, if appropriate, significant others to perform a neurobehavioral status exam, which includes screening for impairments in acquired knowledge, attention, language, learning, memory, problem solving, and visual-spatial abilities. The physician observes behavior and records responses.
Additionally, if the testing is
only administered by a computer, 96118 would not be compliant either as it requires the testing to be administered by the physician or psychologist. You would need to look at 96120 instead for the neuropsych testing.
