Tips to ease the documentation requirements for CPT 96132

In Documenting for Success: CPT 96132, Part 1, we detailed the requirements for successful documentation of neurocognitive testing using Current Procedural Terminology (CPT®) code 96132, Neuropsychological Testing Evaluation Services. Our analysis of this code suggests that documentation of Testing Evaluation (96132) must accompany Testing Administration (96138) to bill properly for these services. This post adds tips to ease documentation requirements.

Document test evaluation rapidly and accurately

BrainCheck’s clinical report, automatically generated with each test administration, provides norm-based data and decision support to the practitioner. Percentile scores are calculated for each of the five core neurocognitive tests, as well as a composite score.

The report gives guidance reflecting brain health at the domain level (e.g., immediate/delayed memory, executive function, etc.) as well as an overall level of cognitive function. This readily available information can enable the physician to document the test findings and to interpret test results in light of the wider range of knowledge about the patient.

The report suggests likelihood of cognitive impairment that can aid the physician in determining a specific diagnosis (e.g., mild cognitive impairment vs. early stage Alzheimer’s vs. vascular dementia) as well as prompting changes in treatment approach and plan.

Takeaways

    • BrainCheck’s clinical report provides the physician with the critical data and decision support to document test evaluation rapidly and accurately.
    • As a reminder, CPT 96132 encompasses face-to-face as well as a review of medical history, integration of other labs/diagnostics, medical decision making and report writing.
    • In aggregate, 31 minutes of combined activity satisfies the criteria for one hour of physician activity.

We’ve often come to expect the negative financial impact from Medicare coding changes and fee schedules. The new codes and fee structure give an opportunity to enhance reimbursement as well as patient care. BrainCheck’s reports give doctors the key information necessary to document for success.


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.