Neurology & Pain Management Coding Alert

Hint: Documentation of extended or long-term recording makes a difference.

EEGs are a simple assessment for your physician to perform, but that doesn’t mean the coding is always easy. Focusing on certain details can make all the difference in your code selection and reimbursement, as our experts show in five common scenarios. 

1. Know How to Report ‘Awake and Asleep’ State

Typically, physicians use 95816 (Electroencephalogram [EEG]; including recording awake and drowsy) and 95819 (Electroencephalogram [EEG]; including recording awake and asleep) to identify abnormalities associated with the transition from awake to sleep or vice versa.

The key: When trying to choose between 95816 and 95819, let the circumstances that prevail during testing determine the code you report.

For example, your neurologist orders an EEG for a patient who is being seen for treatment resistant seizures (780.39, Other convulsions). The physician orders an awake and asleep study (95819) because changes commonly associated with seizure disorders such as epilepsy (345.x) tend to occur during those periods of transition.

Important: As with any type of coding you do, don’t automatically report the procedure the physician orders without verifying the details. If you review the test results for the example above and the person was awake and asleep, bill 95819; if the patient didn’t fall asleep, bill 95816 instead.

Another possibility: CPT® includes a third code for EEG, 95822 (Electroencephalogram [EEG]; recording in coma or sleep only). As seen by the descriptor, only report the “sleep only” code for patients who are comatose, anesthetized, or neonates.

2. Include Modifier for E/M on Same Day as EEG

Your physician sometimes will provide an additional E/M service on the same day he performs a diagnostic EEG study. You can report both services, but some payers require you to append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M code. Including the modifier shows the payer that your physician’s two services (the E/M and the EEG) were separate and distinct from one another.  

“This should reflect the decision to perform the EEG was based upon the E/M encounter,” says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center, in Edison.

“There isn’t a NCCI bundling edit between the two EEG codes and either the new or established patient E/M codes,” adds Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, of MJH Consulting in Denver, Co. “Some commercial payers, however, may use their own proprietary bundling edits that may require use of modifier 25.” 

3. Understand What Qualifies as ‘Extended’ EEG 

Coders sometimes wonder whether an EEG counts as “extended” because of the time involved or because of additional assessments or sessions. The correct answer is that an extended EEG is one with monitoring that lasts more than 40 minutes.

According to CPT® section guidelines, “Codes 95812-95822, 95950-95953 and 95956 use recording time as a basis for code use. Recording time is when the recording is underway and data is being collected. Recording time excludes set up and take down time.” 

“Since these codes are time based, it’s important that coders are clearly aware of what should be used to define the ‘time’ that determines the code that is reported,” Hammer says.

A “typical” EEG (for example, 95816, 95819 or 95822) lasts about 20-40 minutes, according to CPT® guidelines. For monitoring that lasts 41 minutes to one hour, submit 95812 (Electroencephalogram [EEG] extended monitoring; 41-60 minutes). For monitoring of more than an hour, report 95813 (...greater than one hour).

Caution: Do not report an extended EEG and a routine EEG on the same claim. The extended EEG codes are not add-on codes but are designed to replace 95816, 95819, or 95822 for diagnostic EEG testing lasting 40 minutes or more.

Example: The physician meets with a new patient, who complains of memory loss (780.93). The physician performs a 50-minute EEG to determine the nature and cause of the memory loss. In this case, report 95812 for the EEG and the appropriate E/M code, with modifier 25 appended for the initial office visit if that meets your payer’s requirements. Attach diagnosis 780.93 to both codes.

4. Meet the Criteria for Long-Term EEG Monitoring 

According to Medicare and most third-party payers, your physician first must have conducted conventional EEG studies (such as 95816, 95819, 95822 or 95827) to determine medical necessity for the more extensive tests before you can report long-term monitoring. A typical Medicare coverage policy states simply, “Reimbursement [for long-term EEG monitoring] is limited to patients in whom a seizure disorder is suspected, but unconfirmed by conventional EEG studies.”   

Medicare NCD 160.22 includes the following excerpt: “Ambulatory EEG monitoring is a diagnostic procedure for patients in whom a seizure diathesis is suspected but not defined by history, physical or resting EEG. Ambulatory EEG can be utilized in the differential diagnosis of syncope and transient ischemic attacks if not elucidated by conventional studies. Ambulatory EEG should always be preceded by a resting EEG. Ambulatory EEG monitoring is considered an established technique and covered under Medicare for the above purposes.”  This policy applies to all Medicare jurisdictions.

Long-term EEGs are “seizure-focus” in nature, meaning the physician orders the tests to track and analyze brain seizures, such as those common in patients with epilepsy. Specifically, these tests allow physicians to pinpoint the reasons for seizures and to help them localize the portion of the brain affected. Your code choices for long-term monitoring include: 

• 95950 – Monitoring for identification and lateralization of cerebral seizure focus, electroencephalographic (e.g., 8 channel EEG) recording and interpretation, each 24 hours
• 95951 – Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, combined electroencephalographic (EEG) and video recording and interpretation (e.g., for presurgical localization), each 24 hours
• 95953 – Monitoring for localization of cerebral seizure focus by computerized portable 16 or more channel EEG, electroencephalographic (EEG) recording and interpretation, each 24 hours, unattended
• 95956 – Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, electroencephalographic (EEG) recording and interpretation, each 24 hours, attended by a technologist or nurse. 

Example: A patient has extended convulsive seizures (or status epilepticus, 345.3x) – confirmed during previous testing – that require surgery to correct. To find the exact location in the brain where the seizures originate, the physician orders a long-term study (95951).

5. Choose Another Modifier for Shorter Seizure Monitoring

When EEG monitoring lasts less than 24 hours, you may still be able to report the appropriate long-term monitoring code, depending on exactly how long the monitoring lasted. You probably will need to append modifier 52 (Reduced services) to the EEG code.

Explanation: According to current CPT® guidelines, “Codes 95950-95953 and 95956 are used per 24 hours of recording. For recording more than 12 hours, do not use modifier 52. For recording 12 hours or less, use modifier 52.”