How to Bill a Concussion Follow-Up Visit 

A concussion follow-up visit is typically billed as an E/M visit plus, where the work occurred and is documented, one or more separately billable services: a neurobehavioral status exam (96116/96121), neuropsychological testing (96132/96133, 96136–96139, 96146), or Remote Therapeutic Monitoring (98975, 98976–98978, 98984–98986, 98979, 98980/98981) for between-visit symptom and cognitive data.

This page provides general educational information about CPT and RTM billing codes. It is not coding advice, a guarantee of reimbursement, or a substitute for your own compliance review. Payer coverage and documentation requirements vary by plan and can change — verify current requirements with CMS, your Medicare Administrative Contractor, and each payer before billing.

Why Concussion Follow-Up Visits Are Under-Coded

A typical follow-up encounter after a concussion diagnosis involves more than the E/M-level history and exam: clinicians commonly review symptom scale trends (e.g., PCSS), screen for mood or sleep disruption, assess cognitive complaints, and decide on return-to-play, return-to-learn, or return-to-work status. Much of that work — reviewing patient-reported data collected between visits, interpreting cognitive test results, or managing a device-based monitoring program — maps to codes that are billable separately from the E/M service but are frequently left off the claim because the workflow to capture and document them doesn't exist in a typical practice.

The Codes That Commonly Apply to a Follow-Up Visit

1. The E/M Visit Itself

The office/outpatient E/M code (not detailed here) covers the physician's history, exam, and medical decision-making for the visit. Everything below is potentially billable in addition to, not instead of, the E/M service, subject to each payer's same-day billing and modifier rules.

2. Neurobehavioral Status Exam — 96116 / 96121

If the clinician performs a face-to-face clinical evaluation of thinking, reasoning, and judgment (orientation, attention, memory, executive function, language, visuospatial ability) through interview, record review, and mental status exam — distinct from standardized psychometric testing — this may be billed as 96116 for the first hour and 96121 for each additional hour. This is not the same as ordering a formal test battery, and some payers restrict billing 96116 and 96132 on the same date for the same patient.

3. Neuropsychological Test Evaluation — 96132 / 96133

When the physician or QHP integrates formal test data, other clinical information, and history into an interpretation, treatment plan, and report, that evaluative work is billed as 96132 (first hour) and 96133 (each additional hour). This is separate from test administration, which is billed under a different code depending on who performed it.

4. Test Administration — 96136/96137, 96138/96139, or 96146

Administration and scoring of two or more standardized tests is billed based on who administers them: the physician/QHP personally (96136/96137, 30-minute increments), a supervised technician (96138/96139, 30-minute increments), or an automated/computer platform (96146, billed once per date of service regardless of duration). Per CMS's Psychological and Neuropsychological Testing FAQ (opens in a new tab), multiple distinct, clinically appropriate testing codes may be billed on the same date when genuinely different tests were administered through different pathways.

5. RTM for Between-Visit Monitoring — 98975, 98978, 98980/98981, 98979

If the practice sets patients up on a monitoring program that collects symptom, mood, sleep, or cognitive data between visits and a clinician reviews that data and has at least one real-time interactive communication with the patient during the month, RTM codes may apply: 98975 for initial setup/education (billed once per episode), a device-supply code for the monitoring period (98978 for 16–30 days of cognitive-behavioral-therapy-related monitoring data in a 30-day period, or the newer 98986 for 2–15 days of data, effective for CY2026), and a treatment-management code for clinician time spent reviewing and acting on the data (98980 for the first 20 minutes per month, 98981 for each additional 20 minutes, or 98979 for a 10–19 minute lower-threshold month). Only one device-supply code and one treatment-management base code may be billed per patient per 30-day/monthly period.

A Worked Example (Illustrative Only, No Dollar Amounts)

A patient returns three weeks after a sports-related concussion. Between visits, the patient completed weekly symptom and sleep check-ins through a monitoring program. At the follow-up:

• The physician conducts the E/M visit, reviewing trends in the between-visit data.
• The physician also performs a focused neurobehavioral status exam addressing persistent attention and memory complaints, documented with total time — potentially billable as 96116.
• Because the patient was enrolled in a monitoring program that collected at least 16 days of data in the prior 30-day period, and the clinician had a documented real-time call with the patient that month reviewing the data, the practice may separately bill 98978 (device supply) and 98980 (treatment management), in addition to the 98975 setup code billed once at program start.

Every element depends on what was actually performed and documented — this scenario illustrates how the codes can combine, not a template to bill by default.

Documentation Checklist for the Visit

• Total time (or start/stop times) for any time-based code (96116/96121, 96132/96133, 96136–96139)
• Number and names of standardized tests administered, and who administered them
• For RTM: dates of data transmission supporting the device-supply code's duration threshold, and documentation of at least one real-time interactive communication during the billed month
• Clear medical necessity tying the service to active concussion management, not routine follow-up alone
• Supervision documentation where a technician performed testing (see technician supervision rules)

Common Reasons These Claims Get Denied

• Time-based codes billed without documented start/stop times or total minutes
• Add-on codes (96121, 96133, 96137, 96139, 98981) billed without their required base code on the same claim
• RTM device-supply code billed without enough transmitted days of data in the period, or two device-supply codes (short- and standard-duration) billed for the same 30-day period
• RTM treatment-management code billed without a documented real-time interactive communication that month
• Same-day E/M and testing/RTM codes billed without documentation supporting that the services are separately identifiable

Kavera Operational Close: How Kavera Handles This

The Kavera protocol maps to this page directly: first visit (96116 or 96132), enrollment (98975), weekly check-ins and brain training (98978), monthly review and telehealth (98979 or 98980/98981), re-evaluation (testing codes again). One patient, one program, every step documented. Self-Serve practices run this with their own staff. On Managed, Juliet Mott's team runs it and bills it under your credentials. Educational, not coding advice. Verify requirements with CMS, your MAC and each payer.

FAQ

Can I bill an E/M visit and RTM codes on the same day?

Both can apply to the same episode of care, but same-day billing rules and modifier requirements vary by payer and by which specific codes are involved. Confirm current same-day billing rules with CMS and the relevant payer before submitting a claim.

Do I need a device to bill RTM for concussion monitoring?

RTM codes are built around a device or platform that collects and transmits patient-reported or physiologic data over a monitoring period; a monitoring program that captures symptom, sleep, or cognitive data between visits is the kind of activity these codes are designed to support, subject to each code's specific requirements.

Can a nurse practitioner bill the neurobehavioral status exam code?

CMS guidance identifies physicians and qualified health care professionals (which can include NPs within their scope of practice) as eligible billers for 96116/96121; verify eligibility and any state-specific scope-of-practice limits before billing.

What's the difference between 96132 and 96116 for a follow-up visit?

96116/96121 covers a face-to-face clinical status exam of cognitive domains through interview and observation, while 96132/96133 covers the evaluative work of interpreting formal standardized test data and integrating it into a report. They are distinct services with distinct documentation requirements, and some payers limit billing both for the same patient on the same date.

How many RTM codes can I bill in one month for one patient?

Only one device-supply code (standard- or short-duration variant) and one treatment-management base code (98980 or 98979) may be billed per patient per monthly/30-day period, per CMS's non-additive billing rule for these codes.