Neurology & Pain Management Coding Alert

Question: My neurologist administered an EEG lasting for 20 minutes. Her documentation indicates that during the testing, the patient came close to losing consciousness, but never actually fell asleep. What is the correct code under these circumstances?

Texas Subscriber

Answer: Since your neurologist documents that the patient did not fall asleep, you should submit 95816 (Electroencephalogram [EEG]; including recording awake and drowsy). Coding EEG tests depends heavily on correct physician documentation. There can be a fine line between "drowsy" and "asleep," but you should report 95819 (... including recording awake and asleep) only if documentation notes that the patient fell asleep.

Tip: Resist the temptation to code 95819 if your neurologist intended to conduct a sleep study but the patient did not actually fall asleep. Billing based on a physician's intention can create compliance issues. Code  and bill only the procedures the providers performed and documented.