Billing FAQ: What Happens When a Patient Comes in Complaining About Memory Problems?

Is that a neurobehavioral status exam or do you bill it as an E/M visit?

With the 2019 revisions in coding for psychological and neuropsychological tests, BrainCheck is providing a series of blog posts giving information and suggestions for the coding of neurocognitive tests, such as BrainCheck, and common scenarios for the use of testing in a clinical practice.

In our last post, we detailed the relevant new codes and gave suggestions for documentation of test results. In this post, we’ll detail likely practitioner activity leading up to BrainCheck administration.

When to bill as an E/M visit

Unless a request for neurocognitive assessment is coming from another practitioner, most of us will see and assess a patient and learn in the course of that visit that potential cognitive impairment exists, prompting the decision to follow up with formal testing.

For many physicians, complaints or signs/symptoms of cognitive impairment will emerge in a broad spectrum medical visit. Such visits, of course, are coded as evaluation and management (E/M) visits; the assessment of cognitive function is only part of a more comprehensive medical visit that will evaluate other medical complaints, provide a review of systems, medical decision making, evaluation of labs/diagnostics, and initiate change in treatment. In this instance, the visit before neurocognitive testing will be coded as a New Patient Visit (E/M 99201-99205) or Established Patient Visit (E/M 99211-99215).

When to bill for a neurobehavioral status exam

An alternative coding option is to provide a Neurobehavioral Status Exam (CPT 96116) if the nature of the visit is solely focused on the assessment of cognition. The Neurobehavioral Status Exam is described as follows:

Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [e.g., 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

In addition to 96116 as an option for physicians, the code is appropriately used by psychologists and neuropsychologists to bill for pre-testing assessment. Psychologists are not authorized to provide E/M services and thus are directed towards this more focused exam and code.


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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