96116: Neurobehavioral status exam, first hour
96116 is the clinical interview and assessment of higher cortical functions: attention, memory, language, executive function, and behavior, done by the psychologist face to face. In an ADHD or autism evaluation it is the structured clinical assessment that sits next to test administration and scoring.
- Kind
- CPT code
- Family
- testing
- Time
- First 60 minutes; 96121 for each additional hour
- Who bills
- Psychologists
- Telehealth
- Eligible
- Add-on
- Stands alone
When to use it
Use it for the clinician's own neurobehavioral status exam time, first hour, with 96121 for each additional hour, when it is a distinct service from test administration and evaluation.
When not to
Do not use it for the time spent administering standardized tests (96136 to 96139) or for integrating results and writing the report (96130 and 96131).
With children and families
With children the exam blends observation, parent report, and direct tasks. Record the domains assessed and the age-appropriate methods. When the exam is delivered by video, note how you adapted tasks and what the parent set up in the room.
Questions about 96116
- Is 96116 part of every ADHD evaluation?
- Not always. It is billed when a distinct neurobehavioral status exam is performed and documented.
- Can 96116 be delivered by telehealth?
- Yes, when the payer allows telehealth testing and the tasks can be validly delivered on video.
Related
General information for licensed clinicians, not billing advice. Insurers reimburse each code differently and payer contracts control; Emora handles the billing.
Bring your license. We bring the families.
Apply to Emora Health. You see your per-session pay inside the application, before any call, and you hear back within 48 hours. Less than 7% of applicants are accepted.