When patients present with cognitive concerns, clinicians often perform several types of work during a visit. This may include medical evaluation, cognitive screening or testing, review of prior records, and discussions with caregivers about safety or functional changes.

For cognitive care activities, most practices are familiar with the neuropsychological testing codes (96136, 96138, 96132). But E/M codes — specifically 99213–99215 — are a billing pathway that can be applied when the requirements for neuropsychological testing codes are not fully met. Cognitive visits frequently qualify for moderate or high E/M levels without providers realizing it, which means reimbursement is either being missed or undercoded.

Depending on the purpose of the visit and the services performed, clinicians may consider billing:

That decision should be based on whether the billing requirements for the service were fully satisfied.

The key distinction between these services lies in the purpose of the work performed.

E/M services focus on the medical evaluation and management of the patient’s condition. Cognitive concerns may be discussed, screened, or reviewed as part of the overall visit while the clinician evaluates symptoms, reviews relevant information, and develops a management plan.

Neuropsychological CPT codes apply when standardized cognitive testing is administered and professionally interpreted as distinct services.

In other words, the question is not whether cognition was discussed — it is whether the requirements for neuropsychological testing were fully met.

Watch the video below for an overview of where E/M fits in cognitive care and how it differs from neuropsychological testing codes.

Cognitive visits often drive higher complexity — but they are frequently undercoded.

Under current CPT guidelines, office/outpatient E/M levels (99202–99215) are selected based on:

Cognition most often impacts MDM, and it can affect all three required elements.

MDM is based on three elements:

Two of the three must meet or exceed a level.

Documentation should show stability and monitoring.

Documentation must show progression and management decisions.

Document acuity, instability, and urgency.

Cognitive visits often involve significant data review — but it must be documented.

CPT allows this when:

The patient cannot provide reliable history due to cognitive impairment.

Example documentation:

History obtained from the daughter due to the patient's moderate dementia and inability to recall medications.

This counts toward Category 1 data, but only if clearly documented.

Risk increases when management decisions are made — not just when diagnoses exist.

⚠ Prescription drug management automatically qualifies as Moderate risk.

Stable dementia

No medication changes

Minimal data

→ 99213

Dementia progression

Independent historian

Labs reviewed

Medication adjusted

Safety counseling

→ 99214

Acute delirium

Workup ordered

Discussion with ED physician

Medication management

High safety concern

→ 99215

Cognitive visits often involve:

If total time exceeds threshold:

Time includes same-day:

Documentation: What's Required

A note that simply states "Dementia – stable" does not meet documentation requirements and will not support the code billed.

Correct documentation should reflect the full picture of the visit. For example:

"Patient presents with known dementia. Daughter accompanied and reports increased confusion over the past three weeks and two recent incidents of leaving the stove on. ADLs reviewed — patient now requires assistance with medication management and meal preparation. TSH and B12 reviewed and within normal limits. Assessed driving safety; counseled family on next steps. Medication adjusted. Plan to recheck cognition in 90 days."

This documents problem complexity, data reviewed, an independent historian, and a management decision — supporting 99214.

Required documentation elements:

Cognition is not automatically high level — but it frequently supports moderate or high MDM when properly documented.

The difference between 99213 and 99214 in cognitive care is usually documentation clarity — not the diagnosis itself.

Questions about coding? Contact our billing team at support@braincheck.com.