Medicine: Central Nervous System Assessments/Tests (Q&A) (September 2016)

September 2016 page 10bb Medicine: Central Nervous System Assessments/Tests Question: The patient was asked by her pain management physician to complete an online assessment regarding her chronic-pain status and risk of potential opioid misuse or abuse. The doctor reviews the completed assessment report, examines her painful right shoulder, and decides to continue the hydrocodone prescription and refer the patient to physical therapy. Is it appropriate to report CPT code 96103 , Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI), administered by a computer, with qualified health care professional interpretation and report , in this situation...

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Note:  The following article synopsis was NOT provided by the AMA. It was created by Find-A-Code/innoviHealth.

Article Overview

This September 2016 CPT Assistant Q&A discusses coding considerations for a computerized patient assessment used in a pain-management setting. It explains the general difference between a pain-focused screening questionnaire and a more comprehensive psychological testing service, and notes the relationship of that testing to evaluation and management visits. The article is useful for coders, billers, and clinicians who work with behavioral health screening, pain management, and office-based testing documentation.

Why This Topic Matters

It helps readers understand whether a computer-based assessment tied to pain or opioid risk belongs with psychological testing reporting or should be treated as a nonreportable screening activity. That distinction affects CPT reporting and documentation workflows in pain management and related specialties.

What You Will Learn

  • How a pain-related computerized assessment is characterized in a coding context
  • How CPT Assistant distinguishes screening tools from comprehensive psychological testing
  • How the article frames the relationship between testing and evaluation and management services
  • Which broad provider roles are mentioned in connection with computerized testing services

Who Should Read This

  • Medical coders
  • Billing staff
  • Pain management practices
  • Psychologists
  • Physicians and other qualified health care professionals

Codes Discussed


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