Behavioral Health Screening And Testing

Assessment of aphasia and cognitive performance is essential in evaluating individuals with language or cognitive impairments due to neurological conditions such as stroke, traumatic brain injury, or dementia. These evaluations guide diagnosis and treatment planning. Specific CPT codes are used for billing and documentation purposes in clinical settings, reflecting the type and duration of the assessment performed.

96105 – Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report per hour.

96125 – Standardized cognitive performance testing (e.g., Ross Information Processing Assessment) per hour of a qualified healthcare professional’s time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report.

Assessment of Aphasia and Cognitive Performance

The purpose of these tests is to evaluate a patient’s language and cognitive functioning, which may be impaired due to conditions such as stroke, traumatic brain injury, or dementia. Cognitive performance testing involves tasks designed to assess various cognitive domains, including memory, attention, problem-solving, and language skills. The results of these tests are crucial for developing a comprehensive treatment plan, guiding therapeutic interventions, and monitoring the progression or improvement of cognitive impairments over time.

Qualified healthcare professionals, such as speech-language pathologists, neuropsychologists, or clinical psychologists, are authorized to perform these tests. The professional must have the necessary training and expertise to administer the assessments and interpret the results, as outlined by the American Medical Association.

Documentation and Billing Guidelines for CPT Codes 96105 and 96125

A detailed report is required when billing under CPT codes 96105 and 96125. This report must include clinical findings, interpretation of test results, and an explanation of how identified deficits affect the patient’s daily life and functional abilities. The report should provide a comprehensive assessment of the patient’s language and cognitive functioning to support an accurate diagnosis and informed treatment planning.

Both 96105 and 96125 are time-based codes billed in one-hour increments. The total billable time must include:

• Time spent administering the test,
• Time interpreting the results,
• And time preparing the report.

The choice of assessment tools must align with the specific code:

• 96105 typically involves the Boston Diagnostic Aphasia Examination.
• 96125 may include the Ross Information Processing Assessment.
• Other valid instruments include the California Verbal Learning Test (CVLT) and the Neuropsychological Assessment Battery (NAB), which are used when clinically appropriate.

Per the CPT 2025 manual, these services must be:

• Medically reasonable and necessary,
• Appropriately documented in the patient’s medical record.

According to Medicare guidelines (CMS), coverage is provided only when services are medically necessary for the diagnosis or treatment of a condition. Providers must ensure documentation meets Medicare standards and that the services fall within their professional scope of practice.

Although the Billing and Coding: Psychological and Neuropsychological Testing (A57481) article does not list specific ICD-10 codes (since coverage is not diagnosis-based), clinicians are responsible for selecting and documenting the most accurate ICD-10 code that reflects the patient’s condition.

Developmental and Behavioral Screening and Testing

Developmental and behavioral screenings and assessments are essential for identifying delays or concerns in children’s growth, emotional regulation, or cognitive skills. Early detection enables timely intervention and improved long-term outcomes. These services can be administered by qualified healthcare professionals or, in some cases, by auxiliary personnel under the supervision of a qualified healthcare professional. The Current Procedural Terminology (CPT) codes used for these evaluations reflect the scope, duration, and method of testing involved in the review.

CPT Codes and Descriptions

• 96110 – Developmental screening (e.g., developmental milestone survey, speech, and language delay screen), with scoring and documentation per standardized instrument.
• Instruments commonly used include the Ages and Stages Questionnaires (ASQ) and the Modified Checklist for Autism in Toddlers (M-CHAT). This service may be performed by auxiliary personnel such as nurses or medical assistants under the supervision of a qualified healthcare provider. Medicare covers this code under certain conditions.
• 96112 – Developmental test administration (includes assessment of motor, language, social, adaptive, and/or cognitive functioning by standardized developmental instruments) with interpretation and report; first hour.
• 96113 – Each additional 30 minutes (List separately in addition to code for primary procedure). This add-on code is used in conjunction with 96112 when extra time is required for testing.
• 96127 – Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder scale), with scoring and documentation per standardized instrument.
• Tools such as the Patient Health Questionnaire-2 (PHQ-2) and Patient Health Questionnaire-9 (PHQ-9) are commonly used. Like 96110, this service may be completed by auxiliary staff under proper supervision.

Overview and Purpose of Developmental and Behavioral Testing

These tests aim to assess various developmental domains in children, including motor skills, language, social interaction, adaptive behavior, and cognitive abilities. The primary goal is to identify developmental or behavioral concerns early, allowing for timely and targeted interventions that are crucial for improving long-term developmental outcomes.

Qualified Providers and Reporting Requirements

Developmental and behavioral assessments should be performed by qualified healthcare professionals such as pediatricians, psychologists, or other trained providers. The individual administering the test must possess the appropriate training and expertise to conduct the evaluation and accurately interpret the results.

A detailed report is required for billing purposes when these services are provided. The report must include the interpretation of test results, clinical decision-making based on the findings, and documentation of the time spent both administering the test and preparing the report.

Time-Based Coding and Billing Guidelines

CPT codes 96112 and 96113 are time-based and reflect the duration of the assessment:

• 96112 is used for the first hour of developmental testing.
• 96113 is an add-on code billed for each additional 30 minutes of testing.

According to time-based coding guidelines, a unit of time is considered billable once the midpoint of the interval is passed.

Screening vs. Assessment

It is essential to distinguish between screening and assessment. Screening is a brief, preliminary assessment to identify children who may require further evaluation, often using standardized instruments such as the ASQ or M-CHAT. In contrast, assessment (or testing) involves a comprehensive evaluation to diagnose specific developmental delays or conditions, typically using more in-depth instruments and clinical interpretation.

Medical Necessity and Documentation

For CPT codes 96112 and 96113, medical necessity must be documented. This includes the clinical rationale for the evaluation, supported by diagnosis codes that reflect the suspected condition or concern. The medical record must explicitly state the reason for the tests. Coverage determinations are not defined in the Local Coverage Determination (LCD) for either medical or psychiatric diagnoses that may warrant these services.

Note on HCPCS Codes G0513 and G0514

The HCPCS codes G0513 and G0514 do not apply to developmental and behavioral screening or testing. These codes are designated for prolonged preventive services that extend beyond the typical duration of a primary preventive procedure and should not be used in the context of developmental or behavioral assessments.

Neurobehavioral Status Examination

The Neurobehavioral Status Examination is a comprehensive assessment of a patient's cognitive, emotional, psychological, and behavioral functioning. This type of examination is commonly utilized to evaluate individuals with brain injuries, neurological disorders, or psychiatric conditions. The purpose of the exam is to assess the patient's current neurocognitive profile, guiding diagnosis treatment planning, and establishing a baseline for future evaluations.

CPT Codes and Descriptions

The following CPT codes are used for billing neurobehavioral status examinations:

• 96116 – Neurobehavioral status exam, clinical assessment of thinking, reasoning, and judgment (e.g., acquired knowledge, attention, language, memory, planning and problem-solving, and visual-spatial abilities) per hour of the psychologist's or physician's time. This includes both face-to-face time administering tests to the patient and the time spent interpreting the test results and preparing the report.
• 96121 – Neurobehavioral status exam, each additional hour (List separately in addition to code for primary procedure).

For CPT code 96121, which pertains to each additional hour beyond the first, it is essential to document the total time spent on the examination. This includes both the direct face-to-face administration of the test and the subsequent interpretation and preparation of the report. The medical record must reflect the necessity for extended testing and include a detailed account of the services rendered during that period.

Scope and Administration of the Examination

These tests are specifically designed to assess various cognitive functions, including attention, memory, language, executive functioning, and visuospatial ability. The examination is typically performed by a qualified healthcare professional, such as a neuropsychologist, neurologist, or psychiatrist, who has specialized training in both administering and interpreting neurobehavioral assessments.

The healthcare professional conducting the exam is required to provide a detailed report that includes clinical findings, interpretation of the test results, and the implications for the patient's cognitive and behavioral functioning. This report is a crucial component of the exam, supporting informed treatment decisions and care planning.

Time-Based Coding and Documentation Requirements

The CPT codes for Neurobehavioral Status Examinations are time-based. Code 96116 covers the first hour of professional time, and code 96121 is used for each additional hour of professional time. It is essential to accurately report the total time involved, including both the administration of the test and the efforts required for interpretation and documentation. Proper time documentation is crucial for justifying billing and ensuring compliance.

Assessment Instruments

Examples of instruments used in the Neurobehavioral Status Examination include the Mini-Mental Status Examination (MMSE), the Montreal Cognitive Assessment (MoCA), and the Neuropsychological Assessment Battery (NAB). While the MMSE is a commonly used screening tool within this context, it does not have its specific diagnosis code. Instead, the provider must assign the appropriate ICD-10 code that reflects the underlying condition or the reason for testing. These cognitive tools are considered part of the overall neurobehavioral status exam when billed under CPT codes 96116 and 96121.

Billing Compliance and Medicare Coverage

According to CPT Changes 2019, it is crucial to document the specific time spent on the examination to support the use of codes 96116 and 96121. Furthermore, Medicare rules stipulate that these services must be medically necessary and adequately documented in the patient's medical record to be eligible for reimbursement.

Comprehensive Coding for Cognitive and Behavioral Assessments

At BillingFreedom, we understand the critical importance of accurate coding and documentation for cognitive, developmental, and behavioral health services. From CPT codes 96105 and 96125 for aphasia and cognitive testing to 96110, 96112, and 96127 for developmental screenings and 96116 for neurobehavioral status exams, each service requires precise reporting of time, tools used, and clinical necessity. Our expert billing team ensures compliance with Medicare and CPT guidelines, helping providers avoid denials and optimize reimbursements. Whether it’s scoring an M-CHAT or documenting a MoCA, BillingFreedom supports practices with specialized knowledge in behavioral health coding.

Trust us to streamline your billing process, allowing you to focus on delivering quality care to your patients.

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