In simple words: The doctor or a qualified professional spends one hour assessing a patient's thinking, reasoning, memory, and behavior. This includes talking with the patient, reviewing their medical records and other information, and writing a report summarizing their findings.

This CPT code encompasses a comprehensive neurobehavioral status examination performed by a physician or other qualified healthcare professional.The evaluation includes a face-to-face assessment of the patient's cognitive functions (e.g., acquired knowledge, attention, language, memory, planning, problem-solving, and visual-spatial abilities),behavioral observations, and integration of other clinical data (e.g., patient history, other informant interviews). The code covers the first hour of the examination, including both face-to-face time with the patient and the time spent interpreting the test results and preparing a comprehensive report. Additional time beyond the first hour should be billed using code 96121.

Example 1: A patient presents following a motor vehicle accident with suspected mild traumatic brain injury. The physician uses CPT code 96116 to document a comprehensive assessment of cognitive functions, including memory, attention, and executive function, and behavioral observations.The report guides further diagnostic testing and treatment., A patient is experiencing progressive cognitive decline, and the physician performs a neurobehavioral status exam (96116) to evaluate the severity and nature of cognitive impairments. The exam is followed by neuropsychological testing to identify specific deficits and inform treatment recommendations., An elderly patient has experienced a recent stroke, and the neurobehavioral status exam (96116) assesses cognitive deficits, emotional changes, and behavioral disturbances. This comprehensive assessment allows for a tailored rehabilitation program to address the patient's specific needs.

Detailed notes of the face-to-face time with the patient, including specific tests administered, observations, and scoring of results.A comprehensive report summarizing the findings, including a diagnosis and recommendations for treatment, is also necessary.

** This code is intended for the initial hour of the neurobehavioral status exam. Additional time beyond the first hour should be billed with add-on code 96121.Always ensure documentation supports the medical necessity of the service and aligns with payer guidelines.