Neurology & Pain Management Coding Alert

When reporting electroencephalographic (EEG) seizure monitoring, neurologists and neurology coders must be careful to assign not only the proper CPT code(s), but also to document appropriate diagnoses to legitimize the claim. By gaining a better understanding of the diagnoses involved and listing all appropriate signs and symptoms, you can better ensure proper payment.

1. Select the Procedure

Patients undergo EEG monitoring to determine the reasons for seizures and to localize the portion of the brain affected. For patients with specific seizure activity, the most common EEG monitoring procedures are 95950 (Monitoring for identification and lateral-ization of cerebral seizure focus, electroencephalographic [e.g., 8 channel EEG] recording and interpretation, each 24 hours) and 95951 (Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, combined electro-encephalographic [EEG] and video recording and interpretation [e.g., for presurgical localization], each 24 hours). A related procedure, 95953 ( by computerized portable 16 or more channel EEG, electroencephalographic [EEG] recording and interpretation, each 24 hours) more precisely localizes certain types of seizures and, if employed, generally follows monitoring as described by 95950 or 95951.

CMS guidelines specify that 95950-95953 must be performed under the general supervision of a physician in all cases. This means the procedure "is furnished under the physician's overall direction and control but that the physician's presence is not required during the performance of the test. The physician remains responsible for the non-physician personnel performing the procedure."

Lastly, because the descriptors for 95950-95953 specify "each 24 hours," if fewer than 24 hours are provided, report the appropriate CPT code with modifier -52 (Reduced services) appended, advises Neil Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pittsburgh Medical Center at Shadyside, and clinical associate professor in the department of neurology, University of Pittsburgh School of Medicine. Do not reduce your fee: Be sure to indicate the total number of hours of monitoring provided and allow the payer to make the adjustment.

For patients with less well-defined seizure activity, the neurologist may instead choose a procedure from the range 95812-95827. Of these, the most frequently performed are 95812 (Electroencephalogram [EEG] extended monitoring; up to one hour) and 95813 (greater than one hour), as well as 95816 (Electroencephalogram [EEG] including recording awake and drowsy [including hyperventilation and/or photic stimulation when appropriate]) and 95819 ( including recording awake and asleep).

Note that hyperventilation and photic stimulation are not a mandatory part of 95816/95819. Rather, "the neurologist need perform these services only when medically appropriate and not otherwise contraindicated," Busis says. Additionally, 95819 is appropriate if an awake/asleep study was intended even if the patient did not sleep, he advises. You may upcode to 95819 from 95816 if an awake only study is planned but the patient falls asleep.

2. Use Diagnoses to Complete the Claim

Assigning diagnoses for EEG monitoring can be complicated by the ICD-9 manual, which may not provide adequate code choices and which often does not use the same terminology as physicians. For example, within the category 345.x (Epilepsy) coders may choose from a variety of specific diagnoses, but the ICD-9 terminology is not necessarily consistent with how a physician would describe the patient's condition. In these cases, the coder should communicate with the physician directly to select the applicable diagnosis(es). Be sure to code to the highest-documented level of specificity. If, for instance, the physician identifies epileptic seizures as petit mal or grand mal, assign 345.2 or 345.3, respectively. When appropriate and identifiable, assign a fifth digit as well, explains Gregory L Barkley, MD, medical director of the comprehensive epilepsy program at the Henry Ford Health System in Detroit. If the physician can identify the epilepsy as intractable (not responding to ordinary doses of medication), include a "1" as the fifth digit (e.g., 345.81, Other forms of epilepsy, with intractable epilepsy). If the physician notes specifically that the epilepsy is not intractable, assign a "0" as the fifth digit. Assign 345.9 (Epilepsy, unspecified) only when documentation does not support a more precise epilepsy diagnosis.

If seizure activity cannot be classified as epileptic, 780.39 (Other convulsions) is a best code choice, Barkley advises, although other diagnostic categories may also apply if seizures result from psychological or psychiatric disorders. For example, a patient's seizures prove to be manifestations of extreme stress or phobia. In this case, you may assign an appropriate diagnosis from the 300-series (Neurotic disorders) codes to provide further support for 780.39.

In other cases you may provide secondary diagnosis codes such as cerebral palsy, late effects of stroke or vascular malformation, for instance. "Payers know that seizures often accompany these conditions," Barkley says. "Noting such conditions will provide additional information, easing payment and avoiding a follow-up conversations with the payer."

3. Provide Support With Signs and Symptoms

When a definitive diagnosis is not know, signs and symptoms coding can provide justification of diagnostic testing such as EEG, says Cindy Parman, CPC, CPC-H, co-owner of Coding Strategies Inc., a healthcare consulting firm in Dallas, Ga. Generally, the more signs and symptoms that can be documented as long as they pertain to the current problem the better. You can find most signs and symptoms codes in Chapter 16, Volume I of ICD-9 ("Symptoms, Signs and Ill-Defined Conditions," 780-799), although there are exceptions (for instance, 729.5, Pain in limb). For patients exhibiting seizures but for which a definitive diagnosis is unavailable, common signs and symptoms diagnoses might include sudden collapse, loss of speech or movement, lack of response or even sleep disturbance.

In most cases, noting signs and symptoms in the medical record is simply a matter of documentation. "The physician is already considering all the factors involved in the patient's care," Parman says. "If he or she orders a diagnostic test, there must have been some signs or symptoms that prompted the decision. But you must document the signs and symptoms so that the insurer understands the necessity of testing. If the physician cannot substantiate the need for additional procedures through documentation, the need probably isn't there."