Making the Most of CPT 96125: Standardized Cognitive Performance Assessment

96125: Standardized cognitive performance testing (e.g., Ross Information Processing Assessment) per hour of a qualified healthcare professional's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report.

All the details of how to use this code can be located on the Portal in the

Cognitive Performance Assessment POSTette (1).pdf

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✅ When Is 96125 Appropriate?

While 96125 is separately billable during treatment (or as part of a re-evaluation), your documentation in the initial evaluation should lay the foundation for why additional standardized cognitive testing may be necessary. This process supports medical necessity and reduces the risk of denial under Medicare Part B.

For example, in the initial evaluation or updated plan of care, include:

• A description of cognitive-linguistic impairments that require further in-depth assessment

• Statement of limitations of brief tools or informal observation, noting that standardized testing will be conducted to guide treatment

• Mention of need to establish cognitive baselines, monitor recovery, or differentiate between cognitive and language components

Example documentation: "Patient demonstrates significant deficits in attention, memory, and executive function per clinical observation and SLUMS (17/30). Due to limitations of these informal tools, formal standardized testing (e.g., RIPA-G2) will be administered during treatment sessions to determine baseline function and guide individualized cognitive-linguistic intervention."

⚠️ Be Mindful of the Tools Used

96125 must be paired with a standardized cognitive assessment, not a brief screening tool. For example:

• DO use: RBANS, CLQT+, FLCI, or RIPA

• DON’T use: SLUMS, MOCA, BIMS, or MMSE (These are brief cognitive starter tests, not full standardized batteries.)

In the TENS note, include:

• Name of the standardized assessment used e.g., “RIPA-2”, “CLQT+”, “FLCI.”

• Test domains assessed and relevant scores.

  Summary: “Impaired delayed memory (5/15), reduced auditory processing (65th percentile), etc.”

• Interpretation of results

o What do the scores mean in terms of the patient’s functional cognition?

o Relate findings to safety, attention, problem-solving, executive function, etc.

• Impact on function and goals

o Link findings to ADLs, communication, safety awareness, or ability to participate in care.

• Plan based on results

o e.g., “Results support continued skilled intervention targeting compensatory memory strategies and safety training in self-medication tasks. “

FYI: 96125 is a time-based, hourly code. Medicare follows the “midpoint rule”:

• You must provide at least 31 minutes of total service time (face-to-face + scoring + interpretation + report writing) to bill 1 unit.

What About Aphasia?

For language-focused standardized testing, such as the WAB, BDAE, or CADL, use CPT 96105, which follows the same guidelines as 96125 but is specific to aphasia evaluations.

In summary, use of CPT code 96125 can be a powerful tool to help both SLPs and OTs account for the extensive time needed to complete standardized cognitive assessments.