Documenting CPT 96138 and Establishing Medical Necessity for Cognitive Testing

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Meeting CPT 96138 documentation requirements and using neurocognitive tests to screen new patients[/vc_custom_heading][vc_column_text]The following questions were submitted during our webinar, Billing & Coding Update: 2019 Psychological and Neuropsychological Testing Codes, on June 4, 2019.

1. How should BrainCheck be documented to meet the standards for two or more tests (any method) in Current Procedural Terminology (CPT®) code 96138?

BrainCheck is a test administration platform. The individual tests available (i.e., Digit-Symbol Substitution, Stroop Interference Test, Trails A/B, Immediate Recall and Delayed Recall) are validated test instruments and should be listed as the tests administered in the documentation of test administration.

2. Can neurocognitive tests be used for screening purposes for all new patients?

Yes, but there are important considerations for billing tests used for screening purposes.

For Medicare patients, the Annual Wellness Visit (AWV) provides a cognitive screening opportunity. Brief screening tools such as the Montreal Cognitive Assessment (MoCA), the Mini-Mental State Examination (MMSE), or the Mini-Cog© are often incorporated into the AWV. However, cognitive screening is not a separately billable event in the AWV.

Detection of possible cognitive impairment in the AWV may justify formal follow-up neurocognitive testing. The primary neurocognitive testing codes (i.e., CPT 96138 for test administration by technician and CPT 96132 for test interpretation and feedback) are expected to be based on clear individual medical necessity, rather than for screening purposes.

Watch the webinar

Register to watch the on-demand webinar, “Billing & Coding Update: 2019 Psychological and Neuropsychological Testing Codes.”

Our billing experts provide a midyear update on the CPT codes and modifiers for psychological and neuropsychological testing services, including what’s new with the modifiers for CPT codes 96138 and 96132, how to meet the documentation and time requirements for CPT 96132, which health care providers can bill for the psychological and neuropsychological testing codes, and more.

Use the timestamps below to fast-forward to these questions in the webinar recording above:

    • 9:29:00: How should BrainCheck be documented to meet the standards for two or more tests (any method) in CPT code 96138?
    • Can neurocognitive tests be used for screening purposes for all new patients?



Please let us know of your questions, comments, and experiences in using neurocognitive testing at

The information provided in this document was obtained from third-party sources and is subject to change without notice as a result of changes in reimbursement laws, regulations, rules, and policies. All content on this document is informational only, 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. A determination of medical necessity is a prerequisite that BrainCheck, Inc. assumes will have been made prior to assigning codes or requesting payments. 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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