Understanding 96116

September 1, 2006

Can a 96116 with diagnosis code v79.9 be reported separately from an E&M code? A drug rep is instructing one of our physicians that this is true. As far as I can tell from the CPT book, this assessment is part of the E&M.

Question: Can a 96116 with diagnosis code v79.9 be reported separately from an E&M code? A drug rep is instructing one of our physicians that this is true. As far as I can tell from the CPT book, this assessment is part of the E&M.

Answer: The code 96116 is brand new for 2006, as you probably know.

The E&M does include a "mini-mental status exam," but 96116 seems to exceed this somewhat cursory review. It should result in a full report and use several types of tests, according to the description in the Medicine section of CPT.

Also, note that it is a per-hour code (not per 10 minutes), including reviewing test results and writing a report, and is for use for face time only with physicians or psychologists.

It is more substantive than what might be included under E&M.

That said, it might still be that your payers may not want to pay you for both with a -25 on the E&M.

You might place some calls to payers or closely review your EOBs and responses to denials when you start out.