When it comes to CPT 96132—the code for neuropsychological test evaluation services—documentation is everything. Missing even a single detail can result in claim denials, delayed payments, or payer audits. The good news? With the right workflow, documenting for 96132 doesn’t have to be complicated.
In fact, using the “text interpretation documentation” from the interface section ensures you’re covering every essential requirement—without starting from scratch each time.
Here’s a quick, practical guide to getting your documentation right and getting paid—faster.
1. Minimum Time Spent – 31 Minutes (No Exceptions!)
CPT 96132 is a time-based code, and you must document at least 31 minutes to bill it. This includes the total time spent interpreting test results, integrating findings into the clinical picture, providing feedback to the patient/family, and making recommendations.
Example time statement:
“The time spent reviewing and interpreting the cognitive testing results was 31 minutes, including integrating patient data, discussing the results with the patient, family, and/or caregiver, and developing the treatment/assessment plan.”
Pro Tip: The Interpretation section includes this language automatically when using the “Copy Documentation to Clipboard” feature.
2. Core Documentation Elements (All Included in the Interpretation Text)
To support your 96132 claim, your documentation must include four clinical pillars:
Reason for Testing
Clarify why the assessment was needed—whether it’s due to memory concerns, functional impairment, behavioral changes, or a referral from a physician.
Example: “Cognitive or memory concern (no recent injury) reported by the care partner.”
Tests Administered
List the specific cognitive assessments used.
Example: Trails A, Trails B, Stroop, Digit Symbol Substitution, Immediate Recognition, Delayed Recognition
Test Results
Include individual test scores and percentile rankings.
Example: “Stroop: 85th percentile (scaled standard score of 115)”
“Immediate Recognition: 19th percentile (scaled standard score of 87)”
Interpretation of Results
Explain what the results mean clinically.
Example: “These results suggest the patient’s presence of cognitive impairment is unlikely. The patient’s overall cognitive test performance was a standard score of 111 out of 200, which is in the 76th percentile when compared to individuals of a similar age.”
Pro Tip: All of the above appear automatically in the copied Interpretation note—making documentation fast, easy, and audit-ready.
3. Additional Requirements for Full Compliance
Beyond the core elements, payers expect to see the following:
Recommendations for Intervention
Outline any suggested follow-up, referrals, or care plan changes.
“Recommend ongoing monitoring and reassessment in 12 months due to memory concerns, despite currently normal test results.”
Diagnosis or Rule-Out
Confirm the diagnostic outcome or differential considerations.
“Rule-out mild cognitive impairment—current findings do not support diagnosis at this time.”
Summary of Feedback
Document who received the results.
“Results discussed with patient and caregiver in person with time for questions and clarification.”
Total Time Spent
State how long the interpretation took, even if conducted across multiple sessions.
“Total interpretation and feedback time: 31 minutes.”
All of these elements can be included or easily added using the standard Interpretation template.
In Short: Your CPT 96132 Documentation Checklist
Before submitting your claim, ensure you’ve checked all the boxes:
- At least 31 minutes documented
- Reason for testing included
- Tests administered clearly listed
- Results and interpretation summarized
- Recommendations, diagnosis, and feedback recipients documented
- Total time noted
Need Help?
Even with templates and tools, billing can still be tricky. That’s why our expert team is ready to assist with documentation reviews, ICD-10 guidance, and payer-specific best practices.
Live Support: 888-690-0977
Online Contact: braincheck.com/contact-us
Final Thought
When you use the Interpretation section’s text documentation, you’re already covering the exact components required for CPT 96132. It’s efficient, compliant, and tailored for payer approval. Let’s make billing a breeze—and denials a thing of the past.
