2025 CPT code 96121
(Active) Effective Date: N/A Medicine - Central Nervous System Assessments/Tests Feed
Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professional, each additional hour (List separately in addition to code for primary procedure).
Modifiers may be applicable depending on specific circumstances. For instance, modifier -52 might be used if the service is significantly reduced, or modifier -53 for a discontinued procedure.
Medical necessity for this code should be supported by documentation indicating a clinical need for the extended neurobehavioral assessment. This may include symptoms of cognitive impairment, changes in behavior, or suspected neurological conditions.
The healthcare professional explains the testing process, administers the neurobehavioral status tests, records patient responses, interprets the test results, integrates data, and prepares a comprehensive report. They may interact with the patient, family members, or caregivers.
In simple words: This code covers the additional time a healthcare professional spends assessing a patient's thinking, reasoning, and judgment. It's used when the assessment takes longer than one hour and includes the time spent talking to the patient and analyzing the results.The assessment looks at things like memory, language skills, and problem-solving abilities.
This code represents the additional hours spent conducting a neurobehavioral status exam, a clinical assessment of a patient's cognitive functions and behavior. It includes the provider's face-to-face time with the patient and the time spent interpreting test results and preparing the report.It is used when the exam extends beyond the initial hour covered by code 96116. The exam assesses various cognitive domains such as acquired knowledge, attention, language, memory, planning, problem-solving, and visual-spatial abilities. It may involve interviews, behavioral observations and standardized testing.
Example 1: A patient with suspected early-stage dementia undergoes a neurobehavioral status exam that requires 1 hour and 45 minutes of the clinician's time. 96116 is reported for the first hour, and 96121 is reported for the additional 45 minutes., A patient recovering from a traumatic brain injury is evaluated using neurobehavioral testing, with the exam lasting 2 hours and 10 minutes. 96116 is reported for the first hour, and two units of 96121 are reported for the additional time, as the midpoint for the second hour is passed at 31 minutes. , A child with learning difficulties is assessed to understand the underlying causes. The neurobehavioral exam requires 1 hour and 20 minutes. 96116 is reported for the first hour.96121 is not reported as minimum 31 minutes are needed to report an additional unit.
Documentation should include the total time spent face-to-face with the patient, the types of tests administered, patient responses, the provider's interpretation of the test results, integration of patient data, clinical decision making, and the plan for treatment.
- Specialties:Neurology, Psychiatry, Psychology, Geriatrics, Pediatrics (Developmental and Behavioral)
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Skilled Nursing Facility, Nursing Facility,Psychiatric Facility-Partial Hospitalization, Community Mental Health Center