Mini Mental Status Exam documentation

Critical Thinking Exercises

There is no CPT® code for the Mini Mental Status Exam.

Physicians use the mini mental status exam (MMSE to test a patient's cognitive function. The test is made up of a set of questions, testing the patient’s memory, orientation and arithmetic calculation skills.

There is a copyrighted form of the test available, called the Folstein Test. According to the authors, “The MMSE is a brief, quantitative measure of cognitive status in adults. It can be used to screen for cognitive impairment, to estimate the severity of cognitive impairment at a given point in time, to follow the course of cognitive changes in an individual over time, and to document an individual’s response to treatment.”

Physicians and coders will not find a CPT® code for performing a mini mental status exam. At the beginning of the CPT® section on central nervous system assessments and tests, it reads, "For mini mental status examination performed by a physician, see evaluation and management services codes." Assessing a patient’s memory, orientation, and arithmetic calculation skills are part of an E/M service. Do not use any of the tests in the central nervous system assessment section (96101 to 96125), to report a MMSE.

Payment for assessing these functions is included in the payment for the evaluation and management service. An E/M service includes consults, hospital visits, new or established patient visits. The psychiatric assessment included in the MMSE is part of the 1997 single organ system exam. Or, using the 1997 General Multi-system Exam, there are four psychiatric elements which can be documented. Documenting these may or may not raise the level of service the clinician can bill. But, whether it does or not, there is no separate billing or payment for the MMSE.

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