The 1997 version of Medicare’s Documentation Guidelines for Evaluation and Management Services indicates that “brief assessment of mental status including:
- orientation to time, place and person;
- recent and remote memory;
- mood and affect (e.g., depression, anxiety, agitation)” as one of the exam elements for examination.
The physician administration, interpretation and written report associated with the CPT MMSE (Mini Mental Status Exam) is included in the E/M code for the patient encounter and cannot be billed separately.
Do not report CPT 96116 that describes “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” for a CPT MMSE.