CPT Code 96132: Neuropsychological Testing Evaluation, First Hour

What is neuropsychological testing evaluation (CPT 96132)?

CPT 96132 refers to neuropsychological evaluation services by a physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning, and report and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour.

This code is typically used during a detailed clinical assessment to understand how neurological conditions may be affecting behavior, mood, or thinking skills. Neuropsychological testing evaluation services include interviews, cognitive assessments, and review of relevant records to identify patterns of cognitive strengths and weaknesses. These services are often used to support diagnoses such as traumatic brain injury, dementia, ADHD, and other neurological or psychiatric conditions. CPT 96132 covers only the first hour, with additional time billed separately using CPT code 96133.

CPT code 96132 documentation requirements

CPT code 96132 has specific documentation requirements, and it’s important to get them right for proper billing and compliance. In short, your notes should clearly explain why the testing was needed, what was done, and what was found. Here's what you need to include:

• Referral question and diagnosis
• Relevant medical and psychosocial history
• Sources of information (e.g., patient interview, record review, behavioral observations)
• Testing procedures administered
• Clinical decision-making, interpretation of test data, and integration of all findings
• Diagnosis, treatment plan, and recommendations
• Dates of service, billing codes, time spent
• Legible signature of the provider

Also, testing must lead to a clear written report, documented in understandable language, with feedback for referral sources; keep everything signed, legible, and stored in the patient’s record for payer review.

CPT code 96132 billing guidelines

Billing for CPT code 96132 doesn’t have to be confusing. The key is to be clear about what you did and how long it took, especially if you go beyond the first hour.

Here are some billing guidelines for CPT code 96132:

• Bill 96132 for the first hour of neuropsychological evaluation services.
• Use CPT code 96133 for each additional hour needed to complete the evaluation.
• Document all time spent on face-to-face evaluation, test scoring, interpretation, and report writing.
• Include detailed documentation that supports the medical necessity of the neuropsychological testing performed.

Other relevant psychological and neuropsychological testing codes

There’s more to psychological and neuropsychological testing than just CPT 96132. Here are some other commonly used codes that cover test administration, scoring, and additional evaluation time:

Psychological testing evaluation services codes

• 96130: Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour
• 96131: Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; each additional hour (List separately in addition to code for primary procedure)

Neurobehavioral status examination codes

• 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), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; first hour
• 96121: 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), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; each additional hour (List separately in addition to code for primary procedure)

Psychological or neuropsychological test administration and scoring codes

• 96136: Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; first 30 minutes
• 96137: Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; each additional 30 minutes (List separately in addition to code for primary procedure)