How To Use CPT Code 96116

CPT 96116 refers to a neurobehavioral status exam performed by a physician or qualified healthcare professional, covering topics such as the procedure, qualifying circumstances, documentation requirements, billing guidelines, historical information, similar codes, and examples.

1. What is CPT 96116?

CPT 96116 is a medical billing code used to describe a neurobehavioral status exam performed by a physician or other qualified healthcare professional. This exam assesses a patient’s thinking, reasoning, and judgment, including acquired knowledge, attention, language, memory, planning and problem-solving, and visual spatial abilities. The code covers the first hour of face-to-face clinical assessment, as well as the time spent interpreting test results and preparing a report.

2. 96116 CPT code description

The official description of CPT code 96116 is: “Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; first hour.”

3. Procedure

The 96116 CPT code procedure involves the following steps:

1. The physician or qualified healthcare professional conducts a face-to-face assessment of the patient’s thinking, reasoning, and judgment.
2. Questions are presented to the patient, and their answers are recorded, covering areas such as memory, language, reasoning, spatial relationships, and calculations.
3. The patient may be asked to arrange colored tiles into requested patterns or draw diagrams or pictures from memory.
4. The provider spends time interpreting the test results and documenting the findings in a report.
5. This service is reportable per hour of the provider’s time.

4. Qualifying circumstances

Patients eligible to receive CPT code 96116 services are those who require a clinical assessment of their thinking, reasoning, and judgment due to various medical conditions or concerns. These may include neurological disorders, cognitive impairments, or other conditions affecting cognitive function. The assessment must be performed by a physician or other qualified healthcare professional, and the service is reportable per hour of the provider’s time.

5. When to use CPT code 96116

It is appropriate to bill the 96116 CPT code when a physician or qualified healthcare professional performs a neurobehavioral status exam to assess a patient’s thinking, reasoning, and judgment. This code should be used for the first hour of face-to-face clinical assessment, as well as the time spent interpreting test results and preparing a report. If additional hours are required, they should be billed separately using the appropriate codes.

6. Documentation requirements

To support a claim for CPT 96116, the following information should be documented:

• The patient’s medical history and reason for the assessment.
• A detailed description of the face-to-face clinical assessment, including the questions asked and the patient’s responses.
• Any additional tasks or tests performed during the assessment, such as arranging colored tiles or drawing diagrams.
• The provider’s interpretation of the test results and a summary of the findings.
• The total time spent on the face-to-face assessment, interpretation of test results, and report preparation.

7. Billing guidelines

When billing for CPT code 96116, keep in mind the following guidelines and rules:

• Report this code for the first hour of face-to-face clinical assessment and the time spent interpreting test results and preparing a report.
• If additional hours are required, bill them separately using the appropriate codes.
• When reporting 96116 in conjunction with an E/M service, ensure that the neurobehavioral status exam is separate and distinct from the key components of the E/M service. Do not count the time and effort to perform the developmental test toward the key components, history, physical, medical decision-making, or time for selecting the appropriate E/M code. Modifier 59 may be appended to 96116 to differentiate the developmental testing services at the same visit from the E/M services.

8. Historical information

CPT 96116 was added to the Current Procedural Terminology system on January 1, 2006. The code was changed on January 1, 2019, with the previous descriptor being “Neurobehavioral 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.”

9. Similar codes to CPT 96116

Five similar codes to CPT 96116 and how they differentiate are:

• CPT 96132: Neuropsychological testing evaluation services by a physician or other qualified healthcare professional, including interpretation and report.
• CPT 96133: Neuropsychological testing evaluation services with the assistance of a technician, including interpretation and report.
• CPT 96136: Psychological or neuropsychological test administration and scoring by a physician or other qualified healthcare professional, using two or more tests.
• CPT 96137: Psychological or neuropsychological test administration and scoring by a technician, using two or more tests.
• CPT 96146: Psychological test administration using a single automated instrument.

10. Examples

Here are 10 detailed examples of CPT code 96116 procedures:

1. A patient with a history of traumatic brain injury undergoes a neurobehavioral status exam to assess cognitive function and determine the need for further intervention.
2. A patient with suspected Alzheimer’s disease receives a neurobehavioral status exam to evaluate memory, language, and reasoning abilities.
3. A patient with a history of stroke undergoes a neurobehavioral status exam to assess cognitive function and determine the need for rehabilitation services.
4. A patient with multiple sclerosis receives a neurobehavioral status exam to evaluate cognitive function and monitor disease progression.
5. A patient with a brain tumor undergoes a neurobehavioral status exam to assess cognitive function before and after surgery.
6. A patient with Parkinson’s disease receives a neurobehavioral status exam to evaluate cognitive function and determine the need for medication adjustments.
7. A patient with a history of substance abuse undergoes a neurobehavioral status exam to assess cognitive function and determine the need for counseling or other interventions.
8. A patient with a learning disability receives a neurobehavioral status exam to evaluate cognitive function and determine the need for educational accommodations.
9. A patient with a history of concussion undergoes a neurobehavioral status exam to assess cognitive function and determine the need for further evaluation or treatment.
10. A patient with a psychiatric disorder receives a neurobehavioral status exam to evaluate cognitive function and determine the need for medication adjustments or other interventions.