CPT 96132 Documentation in 2020

Refresh yourself on documentation requirements for CPT 96132

Proper documentation for CPT 96132, Neuropsychological Testing Evaluation Services, is essential to getting reimbursed. When the Centers for Medicare & Medicaid Services (CMS) introduced new Current Procedural Terminology (CPT®) codes for neurocognitive testing, BrainCheck shared a few resources focused on documentation requirements.

Now that it’s 2020, here’s a reminder of the documentation requirements.

Documentation Requirements

Documentation of CPT 96132 should encompass the following elements:

  1. Reason for testing, establishing medical necessity
  2. Tests administered
  3. Relevant medical history
  4. Report of test scores and percentiles
  5. Interpretation of test scores
  6. Clinical decision making (e.g., additional tests, medication changes, specialist referrals, etc.)
  7. Changes in treatment plans based on test results
  8. Feedback provided to patients and/or families

These elements include face-to-face patient interactions, interpretation of results and resulting decision making.

Documenting CPT 96132 as a distinct report in the electronic health record (EHR) provides clear evidence of substantial activity related to the use of neurocognitive testing. Including relevant history, reviewing and interpreting test results, documenting changes in treatment plans, and providing feedback to patients and caregivers reflects the doctor’s comprehensive use of test results.

Importantly, reports that lack these elements create a risk that an audit could find test administration lacked clear medical necessity or that the physician used the battery solely for routine screening purposes. Additionally, insufficient documentation could suggest that an hour of physician activity (i.e., more than 31 minutes) did not take place. Any or all of these issues could result in denial and recoupment of fees.

Have a specific question? Send us an email or check out our reimbursement resources page.

BrainCheck Simplifies Documentation for CPT 96132

Using BrainCheck makes documentation for cognitive testing easier in a few ways.

Each cognitive test administration automatically generates a clinical report that provides norm-based data. This report includes a composite score and individual percentile scores for each of the five cognitive domains tested. 

Also, the clinical report functions as a decision support tool providing guidance regarding overall and domain-specific brain health. This guidance suggests the likelihood of cognitive impairment that can aid physicians as they rule in or rule out diagnoses related to brain health.  

By summarizing and compiling critical patient data and clinical support into one accessible document, the BrainCheck platform helps physicians quickly and accurately document test administration and evaluation. 

Moreover, the platform’s convenient Documentation feature provides preformatted clinical documentation. Physicians can even create patient-specific cognitive care plans that can be shared with patients and caregivers from within the platform.

Want to see examples? Download documentation samples here.

Add Reimbursable Cognitive Testing to Your Practice

Accurate and insightful cognitive testing can benefit both your patients and your practice. With regular attention to medical necessity and proper documentation, BrainCheck can play an important role. 

See how BrainCheck can benefit your patients and practice »

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.

About the author

Related Topics

Get BrainCheck’s future articles in your box

Get the latest clinical news and research delivered to your email inbox, and receive our latest articles on topics relevant to your practice.

    Scroll to Top