Neurology
CPT Coding

Evaluation and management coding for neurology office visits follows the AMA's current framework, with E&M level determined by medical decision-making (MDM) complexity. MDM in neurology is frequently high — neurologists routinely manage multiple problems simultaneously, review extensive data (imaging, prior electrodiagnostic studies, laboratory values), and make treatment decisions with significant risk (prescription of potentially dangerous medications, referral for invasive procedures).

High-complexity MDM supports 99215 (established patient) or 99205 (new patient). The documentation must capture all elements: the number and nature of problems addressed, the data reviewed and its source, and the risk of the management plan. When documentation omits the complexity of what was actually done, the note may support only a 99213 or 99203.

The gap between appropriate coding and actual coding is one of the primary drivers of undercoding in neurology practices — and it originates in documentation, not in the billing department.

Electrodiagnostic studies: 95907–95913 for nerve conduction studies (based on number of studies), 95860–95864 for needle EMG (by extremity), 95816/95819 for routine EEG.

Botulinum toxin: 64612 (chemodenervation of muscle for spasticity — limbs), 64615 (chemodenervation for headache — not separately billable for migraine injection by most payers under the current CPT framework), and 95873/95874 for EMG guidance for injection.

Infusion: 96365–96368 for therapeutic infusions. Cognitive assessment: 96116 for neurobehavioral status examination, 96132/96133 for neuropsychological testing evaluation. Lumbar puncture: 62270. Each of these codes has specific documentation requirements that must be met to support the claim.

Undercoding in neurology typically presents as a distribution of E&M codes that is skewed toward lower-complexity levels — a large proportion of 99213s and 99214s for a practice that routinely manages complex neurological conditions. This pattern suggests that documentation is not capturing the full complexity of visits being delivered.

Identifying undercoding requires comparing coded E&M distribution against case mix complexity and against payer benchmarks. Practices where the same physician codes at significantly different levels for similar visits, or where E&M levels are consistently lower than specialty peers, warrant a documentation review.

Scryber's Visualyzer surfaces these coding patterns across providers, flagging encounters where documentation quality may be limiting revenue capture and making the connection between clinical documentation and financial outcomes visible.