Are you making the mistake of reporting 96115 for so-called "mini"-mental status exams (MMSEs)? If so, you're opening yourself up to potential fraud charges. The mental status exam (MSE) described by 96115 is an extensive procedure, while an MMSE is incidental to any E/M services the neurosurgeon provides.
When in Doubt, Consider the 'Time Factor'
Perhaps the easiest way to distinguish an MSE from a "mini" MSE is to consider the time the physician spent providing the service. The MMSE is a 30-element examination, originally created to provide a quick and simple summary test, according to CPT Assistant , Volume 10, Issue 10 (October 2000). In general, the MMSE takes less than 15 minutes to perform and interpret. "It was never meant to substitute for more comprehensive testing," CPT Assistant states.
Physicians administer the exam - which can be a valuable diagnostic tool for stroke victims, Parkinson's patients and others - to test a patient's mental acumen and awareness. "The doctor will test the patient's deductive reasoning skills, ask general questions such as the current date, and have the patient perform some basic math computations," says Helen Wilson, CPC, medical coder and primary-care physician liaison for Cochise Health Alliance, a 31-physician multispecialty medical group in Sierra Vista, Ariz. Also, physicians may use a slightly longer standardized testing tool, which takes up to 30 minutes to perform and interpret.
In contrast to an MMSE, an MSE described by 96115 (Neurobehavioral status exam [clinical assessment of thinking, reasoning and judgment, e.g., acquired knowledge, attention, memory, visual spatial abilities, language functions, planning] with interpretation and report, per hour) involves a lengthy neurobehavioral status examination lasting about one hour. This would include a much more detailed evaluation of the patient's thinking, reasoning and judgment than the comparatively superficial MMSE provides, according to CPT Assistant. In particular, MSE might include a full evaluation of digit span, a four-item similarities task, a 15-item naming task, a 10-word learning test with recall and recognition, four drawing items, and a word-list generation task, as well as other tests.
Include MMSE in E/M Services
Coders searching for a CPT code for MMSE will do so in vain. "The code doesn't exist," says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Systems Inc., which supports family practice physicians in Broomfield, Colo. Rather, if documentation describes only a cursory exam of 30 minutes or less, Medicare considers the MMSE testing to be part of any associated consultation, clinical interview or E/M service and will not pay it as a separate, reimbursable service, she says.
Although you may consider the MMSE when selecting an E/M code, the test does not automatically raise the E/M service level. E/M levels must be chosen according [...]