Documentation Tips for 96136/9613: Get Paid Without the Headache

Billing for CPT codes 96136 and 96138—which cover psychological or neuropsychological test administration—doesn’t have to be complicated. But if you’ve ever faced claim denials, you know how frustrating vague or incomplete documentation can be.

Let’s break down the essentials for accurate billing—so you get reimbursed on the first try, without the stress.

1. Clearly State the Medical Reason for Testing

This is not a box to check off—it’s central to providing medical necessity.

When payers review your documentation, they’re looking for clear rationale. Why was testing needed? What clinical concern or patient complaint justified the service?

Ask yourself:

• Is the patient experiencing memory loss or attention issues?
• Are there behavioral symptoms impacting function or quality of life?
• Is there a suspicion of a neurological condition needing evaluation?

Spell it out in your note. Provide a narrative that connects symptoms to the need for testing.

Example: “Patient reports memory difficulties interfering with work performance. Testing ordered to assess cognitive function and guide treatment planning.”

Pro Tip: When using the BrainCheck administrative interface, the structured documentation fields prompt you to include the reason for testing. This makes it easy to ensure you meet this requirement right from the start.

2. Use an ICD-10 Code That Matches Payer Policy

Even if your documentation is perfect, a mismatched diagnostic code can derail your claim.

Make sure your IDC-10 code:

• Aligns with the payer’s medical necessity policy (e.g., Medicare’s LCD, or Aetna Policy 0158).
• Is clinically relevant to the reason for testing—such as cognitive decline, TBI symptoms, or attention disorders.

Avoid these common pitfalls:

• Using codes that don’t reflect the testing rationale
• Relying on unspecified codes
• Failing to check your payer’s list of covered diagnoses

When in doubt, cross-reference the ICD-10 list from your Medicare MAC, or consult your billing team.

3. Time is Money—Document it Precisely!

CPT codes 96136 and 96138 are time-based. If your note doesn’t support at least 16 minutes, your claim will be denied.

To meet this requirement, your documentation must:

• Clearly specify the total time spent.
• Reflect the cumulative time for test adminstration.
• Avoid vague phrases like “about 30 minutes” or “some time.”

Example: ““The time spent administering cognitive testing was 16 minutes including setting the patient up, creating the order, discussing cognitive testing, answering questions, administering the test / active testing time, ensuring best practices (i.e. no distractions), and uploading the results. This cognitive testing was administered by a technician.”

Use the Administration Interface Wisely: When you use the “Copy Documentation to Clipboard” feature from the administration section, it includes both the time data and administration in one step. This helps ensure your note contains everything needed to support the billed code.

Quick Documentation Checklist

Before you submit a claim for 96136/96138, ask yourself:

• Is the medical reason for testing clearly documented?
• Does the ICD-10 code support medical necessity
• Have you documented at least 16 minutes clearly and precisely?
• Have you pasted the test adminstration text into the chart using the administration tool?

Final Takeaway

Accurate, detailed documentation isn’t just about compliance—it’s about getting paid for the care you provide. By using the built-in documentation tools in the administration interface, you’ll automatically include the critical details that support both medical necessity and time-based billing.

Let’s make denials a thing of the past—and get you paid faster.

Need help? We’ve got you covered.

Even with templates and tools, documentation can be tricky. If you’re ever unsure, our billing experts are ready to support you—from ICD-10 selection to full chart review.

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