CPT Code 96116: Neurobehavioral Status Exam

What is CPT code 96116?

A neurobehavioral status exam is a structured clinical assessment that evaluates cognitive function and mental status, focusing on areas such as attention, memory, orientation, and judgment. Qualified healthcare professionals perform a comprehensive neurobehavioral status exam to identify cognitive impairments and psychological issues resulting from neurological conditions, psychiatric disorders, or cognitive decline. The exam helps clinicians make informed diagnostic decisions, tailor appropriate treatment strategies, and track patient progress over time.

CPT code 96116 is used to report a clinical assessment involving a neurobehavioral status examination typically addressing a patient's cognitive function, including aspects such as memory, attention, orientation, reasoning, and judgment.

Providers perform this face-to-face clinical assessment to diagnose or evaluate cognitive disorders, traumatic brain injury, stroke-related deficits, or dementia. CPT 96116 includes the initial hour of direct patient interaction and the time spent interpreting standardized test results, clinical decision making, and preparing a detailed report.

Healthcare providers commonly use this code to gain valuable insights into a patient’s cognitive abilities, helping guide accurate diagnosis and effective treatment planning.

CPT code 96116 documentation requirements

Complete and precise documentation is essential to substantiate medical necessity and to ensure accurate reimbursement when billing CPT 96116.

Referral reason and medical necessity

Clearly document the referral source and the specific clinical rationale indicating why the neurobehavioral status examination is medically necessary. Include relevant clinical concerns such as suspected dementia, cognitive impairment after a traumatic brain injury, or assessment for neurological conditions.

Relevant medical, psychological, and functional history

Include a detailed summary of the patient's pertinent medical, psychological, and functional history. Highlight previous diagnoses, prior cognitive testing outcomes, mental health history, and any relevant clinical events.

Mental status observations

Record clinical observations of the patient’s mental status during the examination, noting aspects such as appearance, behavior, mood, affect, and general cognitive functioning. These observations support clinical impressions and diagnostic accuracy.

Cognitive domains evaluated

Document specific cognitive domains assessed during the examination, such as orientation, attention, memory, reasoning, executive function, and language. Clearly indicating these domains justifies the scope and comprehensiveness of the exam.

Clinical impressions and diagnostic considerations

Summarize your clinical impressions derived from standardized test results, clinical observations, and cognitive testing outcomes. Include relevant diagnostic considerations and possible conditions indicated by the assessment.

Time spent face-to-face with the patient

Explicitly document the total duration of face-to-face time spent conducting the neurobehavioral exam, interpretation, and report preparation. CPT 96116 specifically covers the first hour of direct clinical assessment and interpretation.

CPT code 96116 billing guidelines

Accurate billing ensures compliance with payer guidelines and proper reimbursement for neurobehavioral assessments.

Billed for the first hour of neurobehavioral evaluation

Use CPT code 96116 for the first hour of the neurobehavioral status examination, which includes face-to-face clinical assessment, interpreting test results, and preparing the assessment report.

Use 96121 for each additional hour

Bill CPT 96121 for each additional hour spent beyond the initial hour of evaluation. Clearly document all face-to-face time and activities supporting additional time billed.

Cannot be billed on the same day as comprehensive neuropsychological testing without separate sessions

CPT code 96116 should not be billed on the same day as comprehensive psychological and neuropsychological testing evaluation services (such as CPT codes 96132–96133) unless the exams are clearly separate encounters with distinct clinical purposes and times documented.

Commonly used in inpatient rehab, TBI evaluations, and cognitive disorder workups

CPT 96116 is frequently billed for evaluations in inpatient rehabilitation settings, assessments following traumatic brain injury, and examinations addressing cognitive impairment due to dementia or neurological disorders. Clearly document the clinical context and necessity in each scenario.

Medical necessity and payer preauthorization

Establish and document medical necessity clearly, as neurobehavioral evaluations typically require payer preauthorization. Verify payer requirements in advance to prevent billing delays or claim denials.

Other relevant CPT codes

• 96121 – Each additional hour of neurobehavioral status exam
• 96132–96133 – Neuropsychological testing evaluation services
• 96136–96137 – Psychological and neuropsychological test administration and scoring by technician
• 96130–96131 – Psychological testing evaluation services by qualified healthcare professional