Neurology & Pain Management Coding Alert

Do not look at frequency and never miss a hidden bundle.

In the last issue, we learned about capturing EEG recording time and appropriately reporting any extended recording. (See "Get Your Routine And Extended EEG Coding Into Gear With These Pointers" in Neurology and Pain Management Coding Alert, Vol. 13, No. 12).

This month, we'll show you how to report the digital analysis and time the physician attendance. We'll also review how to identify Correct Coding Initiative (CCI) bundling edits in the EEG codes. Read on to further learn how to report EEG recording in situations like coma and polysomnography.

Identify Any Digital Analysis

For digital services, you turn to code 95957 (Digital analysis of electroencephalogram [EEG] [e.g., for epileptic spike analysis]). You, however, would not universally bill this code for digital recording of and/or use of an automated spike and seizure detector on a routine EEG, ambulatory EEG or video-EEG monitoring. You specifically report 95957 when your physician uses specialized digital services like three-dimensional (3D) dipole localization or similar techniques for the EEG recording. Digital analysis is often used for presurgical planning as epileptic spike onset must be localized. It would not be appropriate to bill 95957 for source localization when the EEG is normal, i.e. no spikes to analyze.

Payment tip: Your neurologist's documentation should support the additional digital analysis was medically necessary and was performed.

Time the Physician Attendance

When your neurologist uses surface electrodes in the brain to provoke seizures and obtain a mapping, you should use your physician's attendance time, not the recording time, to determine the coding. In this case, you would report 95961 (Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; initial hour of physician attendance) for the first hour of physician attendance.

"Following the CPT® 'passing the time threshold requirement', you would append modifier 52 (Reduced services) with the 95961 CPT® code if the neurologist's physical attendance time is 30 minutes or less," says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, Co.

You report +95962 (... each additional hour of physician attendance [List separately in addition to code for primary procedure]) along with the 95961 CPT® code for every additional hour of physician attendance time.

Don't Count Frequency of EEG Monitoring

If seizures are recurring and preclude the patient from engaging in tasks that involve handling of machinery, you may notice your physician advising the patient to undergo regular monitoring.

For example, if the patient is a driver, the physician may advise at least an annual EEG recording until otherwise needed medically.

Keep in mind: "Driving rules for patients with epilepsy differ depending upon the state in which they live, ranging from seizure-free periods from three months to 18 months. You should always verify with the payer for any diagnostic testing frequency limitations, including EEGs, and make sure it falls under a covered benefit," says Hammer. Typically however, payer coverage policies don't include defined timeframe restrictions and EEG testing can be repeated when required for medical reasons.

Beware Hidden Bundles

An EEG may be bundled in some medical procedures and these may not mention the EEG in code descriptors. An example of such a procedure is the recording of circadian respiration in infants reported with 94772 (Circadian respiratory pattern recording [pediatric pneumogram], 12 to 24 hour continuous recording, infant). CPT® specifically mentions that "separate procedure codes for electromyograms, EEG, ECG, and recordings of respiration are excluded when 94772 is reported." "This parenthetical note is not payer specific, such as Medicare's CCI edits. It is applicable for all payers that use CPT® codes to process their claims," says Hammer.

Your neurologist may find it necessary to also use sphenoidal electrodes in addition to the standard EEG electrodes for the diagnostic testing. "The electrodes are inserted in the patient's cheeks via a needle that is withdrawn after insertion. A thin wire electrode is left in place to record brain electrical activity deep in the temporal and frontal lobes," says Hammer. You can separately report the neurologist's electrode placement with code 95830 (Insertion by physician of sphenoidal electrodes for electroencephalographic [EEG] recording). In contrast, this can be reported in addition to the CPT® code for the EEG diagnostic testing.

Distinguish Routine Polysomnography

Your neurologist may perform other diagnostic testing during the process of investigating the patient for the seizures, so you should know when to separately report the EEG testing.

For example, the patient may undergo extended EEG and sleep staging polysomnography. Your payer will likely deny payment for EEG, saying that it is a component of the sleep staging polysomnography as it typically includes use of a frontal, central and occipital EEG lead monitoring.

Medicare's CCI edits bundle the extended EEG monitoring codes, 95812 (Electroencephalogram [EEG] extended monitoring; 41-60 minutes) and 95813 (Electroencephalogram [EEG] extended monitoring; greater than 1 hour), as components of the sleep staging investigation codes, 95808 (Polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist)-95811 (Polysomnography; sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist). "This particular CCI bundling edit cannot be bypassed with a modifier," says Hammer. "Medicare, and many other payers, will not separately pay for an extended EEG when performed by the same provider on the same date for the same beneficiary."

Report EEG Recorded in Coma or Cerebral Death

Your physician may be requested to interpret an EEG recording for a patient in the ICU. If the diagnostic testing is performed on a comatose or sleeping patient, you would report the diagnostic testing with code 95822 (Electroencephalogram [EEG]; recording in coma or sleep only). If your neurologist only performs the interpretation, you would need to also append modifier 26 (Professional component) to the CPT® code.

In contrast, if the diagnostic test is to determine cerebral death, you would report CPT® code 95824 (...; cerebral death evaluation only). "Remember, ICD-9 for 2012 brought us a new diagnosis code, 348.82 (Brain death) to potentially report your neurologist's findings," says Hammer.

Don't Forget the Final Diagnosis

Remember, EEG is done either for diagnosis or follow-up of a pathological condition. The final diagnosis on EEG typically determines the ICD-9/10 code you report. In particular, look for the diagnostic study findings that your physician establishes after interpreting the EEG recording. "The signs and symptoms would only be reported if the diagnostic study was found to be normal. If that is the case, then you resort to reporting the ICD-9 code for the signs and symptoms that were the underlying reason for the diagnostic study," says Hammer.

Example: For a child who repeatedly drops things due to increasing jerks, the symptoms may be suggestive of myoclonus. If you read the clinical report further, you may see that the EEG confirmed Janz syndrome. The Janz syndrome is also called Juvenile Myoclonic Epilepsy. In such a situation, you report 345.10 (Generalized convulsive epilepsy without intractable epilepsy) and not 333.2 (Myoclonus).