(469) 421-8216
CPT code 96116 is used for neurobehavioral status examinations, a critical component in evaluating cognitive functioning, behavior, emotional regulation, and decision-making capacity. This code applies when a qualified healthcare professional conducts a face-to-face clinical assessment that involves the interpretation of standardized test results, clinical observation, and patient history.
This assessment is often used in neurological, psychiatric, and developmental evaluations and may support diagnoses such as dementia, brain injury, autism, ADHD, and mood disorders.
CPT Code 96116 Description
96116 – Neurobehavioral status exam by a physician or other qualified healthcare professional; includes integration of patient history, clinical interview, and mental status examination with interpretation of findings.
This is a time-based code typically billed per hour, and it is distinct from standardized testing procedures (96132, 96136). It represents the clinician’s direct involvement in evaluating a patient's neurocognitive profile.
Clinical Scenarios When CPT 96116 is Applicable
1. Cognitive Assessment Post-TBI
A patient recovering from a traumatic brain injury is referred for neurobehavioral evaluation due to ongoing memory loss and mood instability. The clinician conducts a 90-minute interview and mental status exam, interpreting prior cognitive testing and patient history.
2. Suspected Neurodegenerative Disorder
An elderly patient presents with symptoms of memory loss, confusion, and impaired judgment. The provider conducts a comprehensive neurobehavioral examination, which includes a review of medical history, cognitive observation, and functional assessment, to support diagnosis and treatment planning.
3. Pre-Surgical Neuropsychological Clearance
Before undergoing deep brain stimulation or epilepsy surgery, a neuropsychologist conducts a neurobehavioral examination to assess emotional readiness, decision-making capacity, and behavioral patterns.
4. Pediatric Behavioral Evaluation
A child with suspected ADHD and autism is evaluated through a structured neurobehavioral exam to differentiate between attention-related and sensory integration issues.
5. Forensic or Disability Evaluation
A clinical psychologist conducts a neurobehavioral exam as part of a legal or disability case to assess capacity, cognitive function, and psychiatric status using structured interviews and interpretation of history.
Documentation Requirements
Duration and Direct Time
Indicate the total face-to-face time spent conducting the exam. 96116 is billed per hour, so a minimum of 31 minutes must be documented for one unit.
Components of the Assessment
Clearly describe the integration of:
- Patient's medical and psychiatric history
- Mental status exam results
- Behavioral observations
- Functional impact on daily living
Interpretation of Findings
Include an interpretive summary discussing cognitive or behavioral concerns, diagnostic impressions, and treatment recommendations.
Clinical Rationale
Explain why a neurobehavioral status exam was necessary and how it contributes to patient care or medical decision-making.
Connection to Other Services
If 96116 is performed in combination with psychological or neuropsychological testing (e.g., 96132), documentation must clearly separate the time and function of each service.
Reimbursement Tips for CPT Code 96116
- Ensure documentation reflects clinical necessity and links findings to patient care decisions
- Clearly distinguish this exam from testing services to prevent overlap or bundling
- Use proper ICD-10 codes for cognitive, behavioral, or neurological symptoms (e.g., F07.89, G31.84, F90.0)
- When performed via telehealth, verify payer-specific requirements and use modifiers like 95 or GT
- Be mindful of frequency limits or medical necessity policies with Medicare or private insurers
Typical Reimbursement Rates
- Medicare: $95–$110 per unit
- Private Insurance: $100–$150 per hour, depending on region
Why MindCare is Your Trusted Partner in Neurobehavioral Billing
At MindCare, we specialize in complex behavioral health billing, and neurobehavioral assessments, such as 96116, require precision in coding, documentation, and payer interpretation. Our experienced billing team ensures accurate capture of time-based codes, compliance with evolving CMS rules, and prevention of audit risks.
With MindCare’s support, providers experience more reliable payments, cleaner claims, and faster reimbursements without the burden of administrative confusion.
Our Advantage in 96116 Billing
- Review and validation of time-based documentation
- Payer-specific guidance to avoid denials
- Expertise in pairing 96116 with testing codes
- Advanced claims tracking and compliance checks
- Real-time support for documentation clarification
We help clinicians stay focused on patient care while ensuring their neurobehavioral assessments are reimbursed with full value. Explore our full suite of Mental Health Billing Services to strengthen your revenue cycle today.
Let Mind Care Billing Help
We help mental health providers use the correct CPT codes, avoid denials, and get paid faster. If you're unsure which code to use, or tired of dealing with rejections, our team can take billing off your plate entirely.
Schedule a Free Consultation with Mind Care Billing today — and leave the coding confusion behind.
