CPT Code 96116: Neurobehavioral status exam, first hour

When to Use CPT 96116

Use CPT code 96116 when billing for neurobehavioral status exam, first hour. This code is used by licensed therapists (LCSW, LPC, MFT, Psychologist) for outpatient sessions.

Adding CPT 96116 to a Superbill

When generating a superbill with CPT 96116, include the ICD-10 diagnosis code, date of service, fee charged, amount paid, and your NPI number. Superbilled pre-fills common therapy CPT codes automatically.

Common ICD-10 Pairings

These diagnosis codes are frequently used alongside CPT 96116:

Documentation Requirements

Document clinical interview, behavioral observations, and cognitive screening results. Include functional status assessment and how findings inform diagnosis.

Common Denial Reasons

• ✗ Testing rationale not established or referral question missing
• ✗ Confused with neuropsychological testing codes (96132-96133)
• ✗ Prior authorization not obtained when required

Got one of these on a remittance? Decode the denial code.

Reimbursement Expectations

OON reimbursement typically 50-70% of UCR. Expect $100-$245 for the first hour.