Summary & Overview
CPT 96116: Neurobehavioral Status Examination, First Hour
Headline: CPT 96116: One-Hour Neurobehavioral Status Exam for Cognitive and Behavioral Assessment
Lead: CPT 96116 designates a one-hour neurobehavioral status examination performed by a qualified clinician that evaluates cognitive domains such as attention, memory, language, reasoning, planning and visual-spatial abilities. This clinical assessment includes both patient contact and the clinician’s time interpreting results and preparing the report.
What the code represents and why it matters: CPT 96116 captures a focused, time-based clinical assessment used to document cognitive and behavioral status in patients with neurologic or neuropsychiatric conditions. Nationally, it supports clinical decision-making, documents baseline and change over time, and provides a standardized way to bill for the clinician’s combined evaluation and reporting time.
Key payers covered: The document considers coverage and administrative context for major national payers including Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.
What readers will learn: The publication summarizes the code’s clinical scope, contrasts related testing codes, outlines common billing modifiers and provider taxonomies, and lists typical diagnostic contexts where the exam is applied. It highlights operational considerations such as time reporting (first hour) and links to adjacent codes for additional testing or subsequent hours. Any missing operational details are identified as not available in the input.
CPT Code Overview
CPT 96116 is a neurobehavioral status examination performed by a physician or other qualified health care professional. It is a clinical assessment of thinking, reasoning, and judgment including domains such as acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities. The code covers both face-to-face time with the patient and time spent interpreting test results and preparing the report; first hour.
Service type: Neurobehavioral status examination / Psychological and Neuropsychological Testing
Typical site of service: Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A 62-year-old patient with a history of traumatic brain injury and progressive memory complaints is referred for a neurobehavioral status examination. The referring neurologist documents new difficulties with attention, recent memory, and problem-solving consistent with suspected cognitive decline. A clinical neuropsychologist or psychologist conducts a face-to-face assessment that includes structured interview, brief standardized testing of attention, memory, language, visuospatial skills, and executive functioning, followed by interpretation of findings and preparation of a written report. The visit typically includes direct patient contact time (interview and testing) plus additional time for scoring, interpretation, and report generation as described by the neurobehavioral status exam code 96116 (first hour).
Coding Specifications
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Modifier
26(Professional Component): Used when reporting only the professional component of the service (evaluation, interpretation, and report) when a separate entity provides the technical component. Applies when the billing practitioner provides the clinical interpretation and report but not the technical administration or provisioning of testing materials. -
Modifier
59(Distinct Procedural Service): Used when the neurobehavioral status exam is separate and distinct from other services provided on the same day (for example, when a separate psychotherapy or medical visit is performed). Indicates a distinct procedural service rather than a component of another billed service. -
Associated provider taxonomies: