Need help choosing the right code?
Ask CasePilot about procedures, modifiers, bundling, and coding guidance.
Try CasePilot© Copyright 2026 American Medical Association. All rights reserved.
A neurobehavioral status exam is a comprehensive clinical assessment conducted by a physician or other qualified healthcare professional to evaluate various cognitive functions and behaviors associated with brain health. This examination focuses on critical areas such as thinking, reasoning, and judgment, which are essential for daily functioning. The assessment encompasses a range of cognitive abilities, including acquired knowledge, attention, language skills, memory retention, planning capabilities, problem-solving skills, and visual-spatial abilities. The underlying causes of brain dysfunction that may necessitate this exam are varied and can include vascular or metabolic disorders, head injuries, infections, exposure to toxins, brain tumors, developmental disorders like autism spectrum disorders, and neurodegenerative conditions. The neurobehavioral status exam is particularly valuable as an initial diagnostic tool, aiding in the identification and characterization of brain dysfunction. It can also be utilized post-diagnosis to monitor the progression of cognitive impairments and to evaluate any changes in symptoms over time. The process typically involves extensive observation and evaluation of the patient's behavior and development, often without the reliance on direct testing instruments. After the completion of the exam, the healthcare professional interprets the findings and prepares a detailed written report summarizing the results. The CPT® Code 96116 is specifically designated for reporting the first hour of this assessment, while 96121 is used for each additional hour of evaluation.
© Copyright 2026 Coding Ahead. All rights reserved.
The neurobehavioral status exam is indicated for a variety of conditions and symptoms that may affect cognitive functioning and behavior. These include:
The neurobehavioral status exam involves several key procedural steps that ensure a thorough assessment of the patient's cognitive and behavioral functions. These steps include:
Post-procedure care following a neurobehavioral status exam typically involves a review of the findings with the patient and possibly their family. The healthcare professional may discuss the implications of the results, recommend further testing if necessary, and outline potential treatment options or referrals to specialists. It is important for the patient to understand the results and any next steps in their care plan. Additionally, ongoing monitoring of the patient's cognitive status may be advised to track any changes over time, especially if the initial assessment indicates significant concerns.
| Short Descr | NUBHVL XM PHYS/QHP 1ST HR | Medium Descr | NEUROBEHAVIORAL STATUS XM PHYS/QHP 1ST HOUR | Long Descr | 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 | Status Code | Active Code | Global Days | XXX - Global Concept Does Not Apply | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 0 - No payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 04 - Physician supervision policy does not apply when procedure is furnished by a qualified, independent psychologist... | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Codes That May Be Paid Through a Composite APC | Type of Service (TOS) | 5 - Diagnostic Laboratory | Berenson-Eggers TOS (BETOS) | T2D - Other tests - other | MUE | 1 | CCS Clinical Classification | 218 - Psychological and psychiatric evaluation and therapy |
This is a primary code that can be used with these additional add-on codes.
| 96121 | Telehealth Service (Medicare) Add-on Code Audio-Only Telemedicine (AMA) Telemedicine Service (AMA) MPFS Status: Active Code APC N 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; each additional hour (List separately in addition to code for primary procedure) |
| 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 95 | Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system. | AH | Clinical psychologist | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | FQ | The service was furnished using audio-only communication technology | GW | Service not related to the hospice patient's terminal condition | GA | Waiver of liability statement issued as required by payer policy, individual case | GC | This service has been performed in part by a resident under the direction of a teaching physician | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | X2 | Continuous/focused services: for reporting services by clinicians whose expertise is needed for the ongoing management of a chronic disease or a condition that needs to be managed and followed with no planned endpoint to the relationship; reporting clinician service examples include but are not limited to: a rheumatologist taking care of the patient's rheumatoid arthritis longitudinally but not providing general primary care services | XP | Separate practitioner, a service that is distinct because it was performed by a different practitioner | CR | Catastrophe/disaster related | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | GQ | Via asynchronous telecommunications system | GZ | Item or service expected to be denied as not reasonable and necessary | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | X1 | Continuous/broad services: for reporting services by clinicians, who provide the principal care for a patient, with no planned endpoint of the relationship; services in this category represent comprehensive care, dealing with the entire scope of patient problems, either directly or in a care coordination role; reporting clinician service examples include, but are not limited to: primary care, and clinicians providing comprehensive care to patients in addition to specialty care | QJ | Services/items provided to a prisoner or patient in state or local custody, however the state or local government, as applicable, meets the requirements in 42 cfr 411.4 (b) | 77 | Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | SF | Second opinion ordered by a professional review organization (pro) per section 9401, p.l. 99-272 (100% reimbursement - no medicare deductible or coinsurance) | 93 | Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system : synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located away at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that is sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. | HE | Mental health program | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | AF | Specialty physician | AG | Primary physician | AJ | Clinical social worker | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | FS | Split (or shared) evaluation and management visit | GN | Services delivered under an outpatient speech language pathology plan of care | GP | Services delivered under an outpatient physical therapy plan of care | GT | Via interactive audio and video telecommunication systems | HP | Doctoral level | KX | Requirements specified in the medical policy have been met | PD | Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days | PN | Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | UC | Medicaid level of care 12, as defined by each state | X4 | Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2019-01-01 | Changed | Description Changed |
| 2006-01-01 | Added | First appearance in code book in 2006. |
Get instant expert-level medical coding assistance.