BrainCheck Billing Audit Checklist | BrainCheck Help Center

Follow this checklist to ensure complete documentation and compliance when billing CPT codes 96136, 96138, and 96132, reducing denials.

📎 Download the full Billing Audit Checklist (PDF): BrainCheck Billing Audit Checklist

CPT Codes 96136 / 96138 – Test Administration

Designed to ensure compliance with documentation for neurocognitive testing under CPT codes 96136 / 96138.

Medical Reason

Ensure the reason for testing aligns with the patient’s symptoms or clinical condition.
Document the reason clearly.

ICD-10 Codes

Verify that ICD-10 code(s) reflect the condition being tested (e.g., dementia, cognitive impairment).

Time Documentation

Confirm at least 16 minutes of administration is documented.
Time must reflect activities such as patient instructions, practice test, environment readiness, and active testing.

CPT Code Appropriateness

Use 96136 if administered by a medical professional.
Use 96138 if administered by a technician.

Time Requirement Template

96136 (Physician/NPP):
“<___> minutes were spent administering cognitive testing by a medical professional. This includes discussing cognitive testing with the patient, going over patient questions, ensuring the patient can read the test, providing practice, and active testing time.”
96138 (Technician):
“<___> minutes were spent administering cognitive testing by a technician. This includes discussing cognitive testing with the patient, going over patient questions, ensuring the patient can read the test, providing practice, and active testing time.”

CPT Code 96132 – Test Interpretation

Designed to ensure documentation supports billing for test interpretation and medical decision-making.

Reason for Testing

Document the medical necessity supporting the need for neurocognitive testing.

Tests Administered

List all tests performed (e.g., Trails A/B, Stroop Test).
Ensure tests align with the documented reason for testing.

Test Results & Interpretation

Confirm results are clearly documented.
Provide a detailed interpretation of results.

Recommendations

Document any referrals, interventions, or follow-up plans.

Diagnosis

State a diagnosis or rule-out diagnosis with follow-up plans.

Feedback

Document feedback given to the patient, family, and/or caregiver.

Time Documentation

Ensure at least 31 minutes of direct patient interaction and interpretation is documented.

Time Requirement Template
“<___> minutes were spent reviewing and interpreting the cognitive testing results, integrating patient data, discussing results with the patient/family/caregiver, and developing a treatment/assessment plan.”

Helpful Tip

For clients not using EHR integration:

Use the “Download Report” feature on the BrainCheck Assess report.
This covers most documentation requirements (tests performed, results, interpretation, diagnosis), saving time and reducing missed elements.

📎 Download the BrainCheck Billing Audit Checklist (PDF):

Billing Audit Checklist_CS030_Rev.001.pdf