Expected physician documentation to support billing CPT 96132

Our last blog posts introduced the new 2019 Current Procedural Terminology (CPT®) codes for neurocognitive testing, including the Centers for Medicare & Medicaid Services (CMS) rationale for the changes, description of the applicable codes, and a brief focus on documentation.

This blog post will dive further into expected physician documentation to support billing CPT 96132, Neuropsychological Testing Evaluation Services.

As described last time, a close read of the 96132 descriptor suggests the following elements, which include both face-to-face and cognitive activities on the part of the physician:

    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 (additional tests, medication changes, specialist referral, etc.)
    7. Changes in treatment plan in light of test results
    8. Documentation of feedback to patient/family

Keeping in mind that this code pays in one-hour increments, it is important to remember that 96132 documentation, as an entry in the electronic health record (EHR) or as a separate report, provides clear evidence of the physician’s substantial activity related to his or her use of neurocognitive testing. Inclusion of relevant history, reviewing and interpreting test results, documenting changes in treatment plan, and providing feedback to the patient and caregivers will reflect the doctor’s comprehensive use of test results.

Reports that lack these elements create a risk that an audit could find a) that the test administration is medically unnecessary, b) that the test battery is used solely for routine screening purposes, or c) that cursory documentation suggests that an hour of physician activity did not take place. Any or all of these issues could result in denial and recoupment of fees.

For examples of sample documentation of CPT 96132, please contact us at info@braincheck.com.


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.