Neurology & Pain Management Coding Alert

Counting the hours and minutes provides one key to accurate coding

Electroencephalograms (EEGs) make up a wide variety of distinct diagnostic procedures, but CPT doesn't always provide the information you need to choose from among the available codes. We asked our experts to fill in the blanks by answering the four most common questions readers ask us about EEGs.

Question 1: How Do I Choose Between 'Drowsy' and 'Asleep'?

When trying to choose between 95816 (Electroencephalogram [EEG]; including recording awake and drowsy) and 95819 (Electroencephalogram [EEG]; including recording awake and asleep), you should allow the circumstances that prevail during testing to determine the code you report, says Anne M. Dunne, RN, MBA, MSCN, practice administrator for South Shore Neurologic Associates PC/Brookhaven MRI, in Bay Shore, N.Y.

Typically, neurologists use 95816 and 95819 to identify abnormalities associated with the transition from awake to sleep or vice versa.

For instance, a patient comes to see a neurologist because of seizures (780.39). The neurologist orders an awake and asleep study (95819) because changes commonly associated with epilepsy tend to occur during these periods of transition.

Don't automatically report the procedure the neurologist orders: As a rule, you shouldn't code the procedure the physician requests, but report what actually occurs during the EEG. If you review the test results and the person was awake and asleep, bill 95819; if the patient didn't fall asleep, bill 95816, Dunne says.

In the above example, for instance, the neurologist orders an awake and asleep study, and the patient does fall asleep during testing. You should report 95819 with a diagnosis of 780.39. If the neurologist provided a separate E/M service (for example, 99204, Office or other outpatient visit for the evaluation and management of a new patient ...) on the same day, you also may report the appropriate E/M code with modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) appended.
 
Follow-up question: What about 95822? You should report the "sleep only" code (95822) for patients who are comatose, anesthetized or neonates.

Question 2: What Qualifies as 'Extended'?

As a rule, you can claim an extended EEG for monitoring lasting 40 minutes or more. A "typical" EEG (for example, 95816, 95819 or 95822) lasts about 20-40 minutes, according to CPT guidelines. For monitoring of 41 minutes to one hour, report 95812 (Electroencephalogram extended monitoring; 41-60 minutes). For monitoring of an hour or more, report 95813 (...greater than one hour), says 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 report an extended EEG and a routine EEG at the same time. The extended EEG codes are not add-ons, but are designed to replace 95816, 95819 or 95822 for monitoring lasting 40 minutes or more.

For example: The neurologist meets with a new patient, who complains of memory loss (780.93). The neurologist performs a 50-minute EEG to determine the nature and cause of the memory loss. In this case, report 95812 for the EEG and 99204, with modifier -25 appended, for the initial office visit. Attach a diagnosis of 780.93 to both codes.

Question 3: When Can We Report Long-Term EEG?

To report long-term monitoring (95950-95951, 95953, 95956), the neurologist first must have conducted conventional EEG studies (such as 95816, 95819, 95822 or 95827) to determine medical necessity for the more extensive tests, according to Medicare and most third-party payer guidelines. 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."

Long-term EEGs are "seizure-focus" in nature, meaning the neurologist orders the tests to track and analyze brain seizures, such as those common in epilepsy patients. Specifically, these tests allow neurologists to pinpoint the reasons for seizures and to help them localize the portion of the brain affected, Dunne says.
 
For example: A patient has extended convulsive seizures (or status epilepticus, 345.3) - confirmed during previous testing - that require surgery to correct. To find the exact location in the brain where the seizures originate, the neurologist orders long-term study 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).

Question 4: How Do I Report Less Than 24 Hours?

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

Skip -52 for 15 or more hours: If the neurologist or technician provides a minimum of 15 hours of monitoring, you may report the appropriate long-term EEG code (for instance, 95951) with no modifiers appended, according to the American Clinical Neurophysiology Society. For nine to 15 hours of monitoring, however, you should append modifier -52 to show that the service provided was less than that described by the reported CPT code. For anything less than nine hours, you should revert back to extended EEG code 95913.