Using CPT 96116 for Telehealth Billing

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“What CPT code should I use?” As clinical practices pivot to telemedicine, many have that question in mind.  For cognitive and behavioral assessment, CMS specifically lists CPT 96116 for telehealth as a reimbursable option.

Current Importance of Cognitive Assessment 

CPT 96116 covers the neurobehavioral status exam. And right now, it’s more important than ever to monitor seniors’ neurobehavioral status. 

Often, the first sign of illness in a senior is a change of mental status. With geriatric patients encouraged to stay home due to their high risk for illness, a change in mental status could easily go overlooked. This change could certainly be an early sign of a larger illness, so it’s important to continue screening and assessment. 

BrainCheck — with it’s at-home assessment capabilities — provides an easy-to-use tool for this mission. Since traditional paper-based tools are challenging to administer via telehealth, the platform provides even greater utility.

Assessment Requirements for CPT 96116

With the expanded coverage announced this week, practices can complete the exam with a virtual visit, while the patient can stay home (or wherever they choose). The Department of Health and Human Services will also exercise discretion regarding HIPAA requirements, allowing the use of any video conferencing platform.

In order to accurately bill for this code, clinicians must complete assessment of several areas of cognition for the patient.

The Braincheck cognitive assessment battery, combined with a few additional questions, can meet the requirements for CPT 96116 for telehealth. 

Use the suggested series of observations and questions below, which should not take more than a few minutes for the patient to answer.

In addition to the domains covered by BrainCheck, these questions will provide clarity regarding orientation, language ability, knowledge, and reasoning. Taken together, this provides a comprehensive neurobehavioral status exam.

These following questions provide examples of how to test the various domains. You can use your own questions, if you prefer, and the results are subjective.

To provide comprehensive cognitive care, it’s most important to establish a baseline for the patient and track changes over time, which requires use of the BrainCheck platform.

Example Observations and Questions

Level of Consciousness

Is the patient alert, confused, delirious, drowsy, or fluctuating?



e.g., What is your name?


e.g., Where are you right now?


e.g., What is today’s date?


Verbal Speech

e.g., Describe the room you are in.

Verbal Comprehension

e.g., “Follow my command: comb your hair with your right hand; touch your nose with your left hand, etc.

Verbal Repetition

e.g., “Repeat after me: The big old fox ate the purple sweet potato on Tuesday.”

Object Naming

e.g., “I am going to show you an object. You tell me what it is.” (paper clip, watch, etc.)

Knowledge & Reasoning

Memory of Facts and Events

e.g., Where is the Eiffel Tower?


e.g., What would do if you lost the keys to your home?

Reimbursement Requirements for CPT 96116

Neurobehavioral status exams must be completed by a physician or other qualified healthcare professional. Keep in mind, CPT 96116 covers the first hour of evaluation. This includes face-to-face time with the patient, time interpreting test results, and preparing the report. Additional guidance for CPT 96116 can be found in a previous post.

Despite the current crisis, we must remain vigilant in screening and assessing cognitive function. With BrainCheck’s at-home assessment capabilities and increased access to telehealth, patients can continue to receive vital cognitive care.

Find more BrainCheck telehealth information here »

DISCLAIMER: The information provided is general in nature and does not cover all situations or all payers’ rules and policies. This content is not intended to instruct medical providers on how to use or bill for healthcare procedures, including new technologies outside of Medicare national guidelines. Medical providers should consult with appropriate payers, including Medicare fiscal intermediaries and carriers, for specific information on proper coding, billing, and payment levels for healthcare procedures. This information represents no promise or guarantee by BrainCheck, Inc. concerning coverage, coding, billing, and payment levels. BrainCheck, Inc. specifically disclaims liability or responsibility for the results or consequences of any actions taken in reliance on this information.

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