Billing and Documentation Considerations

BrainCheck supports documentation across common cognitive care workflows but does not determine billing, coding, coverage, or payment.

Billing Considerations

Services delivered using BrainCheck, in some circumstances, may be billed under applicable payer rules when medically necessary, properly documented, and otherwise consistent with payer requirements. Coverage and payment vary by payer, plan, and setting.

BrainCheck follows a documentation-first approach and is designed to fit different practice models:

  • Can be incorporated into clinical workflows that may involve E/M services and CPT-coded procedures, depending on what was performed, how it was documented, and payer requirements.

  • Supports consistent documentation and longitudinal tracking to help teams deliver cognitive care over time.

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Common Billing Pathways

When cognitive concerns come up, clinicians choose how to account for the work performed. Some practices bill distinct testing services, while others incorporate cognitive work into a broader Evaluation & Management (E/M) visit. The right approach depends on what was done, how it was documented, and payer policy.
E/M
CPT
E/M + CPT

E/M (Evaluation & Management)

E/M describes the overall clinical visit—the evaluation, medical decision-making, and care planning for the patient. E/M codes capture:

  • Patient evaluation

  • Medical decision-making
  • Care management activities
  • Clinician time spent on the encounter

Payers allow time-based or medical decision-making E/M selection. Always verify the payer's requirements.

CPT (Current Procedural Terminology)

CPT procedure codes describe specific services performed. For example, standardized test administration and professional interpretation/reporting. Many cognitive-service CPT codes are time-based and require:

  • Medical necessity

  • Role/credential requirements

  • Minimum time thresholds and time documentation

  • Complete supporting documentation

  • Prior authorization (payer-dependent)

In cognitive care, CPT codes commonly used include:

96136 / 96138 Neurocognitive test administration (time-based)
96132 Interpretation and report (time-based)
99483 Cognitive care planning services

 

E/M + CPT (on the same day)

In some workflows, an E/M service and one or more CPT procedure codes may be both billed if each service is medically necessary and separately documented. 

When an E/M service and a procedure code are reported on the same day, a modifier may be required to indicate the services are separately identifiable, based on payer policy.

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E/M

E/M (Evaluation & Management)

E/M describes the overall clinical visit—the evaluation, medical decision-making, and care planning for the patient. E/M codes capture:

  • Patient evaluation

  • Medical decision-making
  • Care management activities
  • Clinician time spent on the encounter

Payers allow time-based or medical decision-making E/M selection. Always verify the payer's requirements.

CPT

CPT (Current Procedural Terminology)

CPT procedure codes describe specific services performed. For example, standardized test administration and professional interpretation/reporting. Many cognitive-service CPT codes are time-based and require:

  • Medical necessity

  • Role/credential requirements

  • Minimum time thresholds and time documentation

  • Complete supporting documentation

  • Prior authorization (payer-dependent)

In cognitive care, CPT codes commonly used include:

96136 / 96138 Neurocognitive test administration (time-based)
96132 Interpretation and report (time-based)
99483 Cognitive care planning services

 

E/M + CPT

E/M + CPT (on the same day)

In some workflows, an E/M service and one or more CPT procedure codes may be both billed if each service is medically necessary and separately documented. 

When an E/M service and a procedure code are reported on the same day, a modifier may be required to indicate the services are separately identifiable, based on payer policy.

How BrainCheck Supports Documentation Workflows

BrainCheck is built for a documentation-first workflow that supports:

  • Clear clinical records
  • Standardized cognitive assessment workflows
  • Longitudinal tracking
  • Care continuity across visits and settings

Billing decisions remain provider-driven and payer-dependent.

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Documentation Elements That Commonly Matter

Accurate documentation is essential to support billing and reimbursement.

  • Clinical rationale/medical necessity
  • Who performed each component (administration, scoring, interpretation)
  • Time for time-based services (when applicable)
  • Interpretation in clinical context and how it supports the care plan
  • Separate E/M documentation when billing E/M alongside procedures (when applicable)
Doctor-and-Patient

Telehealth and Remote Services

Telehealth coverage for cognitive testing and interpretation varies by payer (Medicare vs commercial), current policy year, and state rules.

What you need to know:

  • Some payers recognize cognitive testing codes via telehealth under specific conditions
  • Always verify current payer telehealth policies before billing
  • Document modality (video/audio) and clinical rationale clearly
  • A modifier may be required to indicate that services are telehealth

Reimbursement Disclaimer

The information provided on this page is for educational purposes only and is not intended as legal, billing, coding, or reimbursement advice. Coverage, coding, documentation requirements, and payment policies vary by payer and are subject to change.

Clinicians and healthcare organizations are solely responsible for determining appropriate billing codes, modifiers, and diagnosis codes, and for ensuring compliance with applicable federal and state laws, payer policies, and documentation requirements.

BrainCheck does not guarantee reimbursement for any service and does not provide billing or legal advice. Users should consult their billing specialists, compliance officers, legal counsel, or payer guidance for specific reimbursement questions.

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Did you know?

Listening to music stimulates more areas of the brain than almost any other activity.

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