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A neurobehavioral status exam is a 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, planning, problem-solving capabilities, and visual-spatial skills. The underlying causes of brain dysfunction that may necessitate such an 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 it can serve both as an initial diagnostic tool to identify and characterize brain dysfunction and as a follow-up measure to monitor the progression of symptoms over time. During the exam, the healthcare professional engages in extensive observation and evaluation of the patient's behavior and cognitive development, often without relying on direct testing instruments. After completing the assessment, the professional interprets the findings and prepares a comprehensive report detailing the results. For billing purposes, CPT® Code 96116 is utilized for the first hour of the exam, while CPT® Code 96121 is designated for each additional hour of assessment and report preparation.
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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 comprehensive assessment of the patient's cognitive and behavioral functions. These steps include:
Following the neurobehavioral status exam, the patient may receive feedback regarding the assessment results. The healthcare professional will discuss the findings and any implications for the patient's cognitive health. Depending on the results, further evaluations or referrals to specialists may be recommended. The report generated from the exam serves as a critical document for ongoing care and may be used to inform treatment plans or additional assessments. It is important for the patient to understand the next steps based on the findings, which may include therapeutic interventions, additional testing, or monitoring of cognitive changes over time.
| Short Descr | NUBHVL XM PHY/QHP EA ADDL HR | Medium Descr | NEUROBEHAVIORAL STATUS XM PHYS/QHP EA ADDL 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; each additional hour (List separately in addition to code for primary procedure) | Status Code | Active Code | Global Days | ZZZ - Code Related to Another Service | 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 | Items and Services Packaged into APC Rates | Berenson-Eggers TOS (BETOS) | none | MUE | 3 |
This is an add-on code that must be used in conjunction with one of these primary codes.
| 96116 | Telehealth Service (Medicare) Telemedicine Service (AMA) Audio-Only Telemedicine (AMA) MPFS Status: Active Code APC Q3 Physician Quality Reporting PUB 100 CPT Assistant Article 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 |
| 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. | 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. | AH | Clinical psychologist | GC | This service has been performed in part by a resident under the direction of a teaching physician | 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. | FQ | The service was furnished using audio-only communication technology | GA | Waiver of liability statement issued as required by payer policy, individual case | GW | Service not related to the hospice patient's terminal condition | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | CR | Catastrophe/disaster related | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | 25 | Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: it may be necessary to indicate that on the day a procedure or service identified by a cpt code was performed, the patient's condition required a significant, separately identifiable e/m service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. a significant, separately identifiable e/m service is defined or substantiated by documentation that satisfies the relevant criteria for the respective e/m service to be reported (see evaluation and management services guidelines for instructions on determining level of e/m service). the e/m service may be prompted by the symptom or condition for which the procedure and/or service was provided. as such, different diagnoses are not required for reporting of the e/m services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of e/m service. note: this modifier is not used to report an e/m service that resulted in a decision to perform surgery. see modifier 57 for significant, separately identifiable non-e/m services, see modifier 59. | 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. | GT | Via interactive audio and video telecommunication systems | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | GZ | Item or service expected to be denied as not reasonable and necessary | HA | Child/adolescent program | HE | Mental health program | HP | Doctoral level | PN | Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | 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 | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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