Neurosurgery Coding Alert

Time the procedure and check if patient was awake, drowsy, asleep, or in coma.

When your physician does an EEG, you will need to need to watch for the patient’s state of consciousness during the procedure and the duration for the procedure. Once you know these two parameters, getting to the right code is an easy job.

Why EEG? Your neurosurgeon will fall back upon EEG testing in a patient who is diagnosed with brain lesions, complains of frequent headaches, or presents after a traumatic brain injury (TBI).

Example: A patient has a routine EEG due to suspicion of a brain lesion or cyst. The EEG confirms the presence of an arachnoid cyst. On the claim, you’d include ICD-10 code G93.0 (Cerebral  cysts) to represent the patient’s lesion.

Here are three steps you can follow to walk to the most accurate EEG codes.

Step 1: Look For Condition of Consciousness to Pick Up the Right Code

For EEG procedures, you can choose form three codes depending up the state of consciousness of the patient during the procedure. If the physician performs the EEG while the patient is awake and drowsy, you’ll report the EEG code 95816 (Electroencephalogram  [EEG]);  including  recording  awake  and  drowsy). When encounter notes indicate that the patient was awake and asleep, you’d report 95819 (… including recording awake and asleep). If the physician documents that she performed the EEG while the patient was in a coma or asleep, you’d choose 95822 (… recording in coma or sleep only).

Make note of four terms: Looking at the descriptors of codes above, you can list four states of consciousness: Awake, drowsy, asleep, and coma. These four terms are key and will help you to navigate to the correct code for EEG. Read through the procedure note and confirm what the patient’s state of consciousness was when the EEG was done.

Why assessments in different conscious states? Your physician will obtain an EEG when the patient is awake and drowsy to confirm that the symptoms/signs persist when the activity of the brain is depressed. Similarly, the testing may be repeated during sleep. To check if the patient has brain activity during state of deep sleep or brain death, your physician will perform EEG in a state of sleep or coma.

Step 2: Accurately Time the EEG Procedures

When your physician performs an EEG, make sure you document how long the recording lasted. The codes 95816-95822 apply to 20 to 40 minutes of recording time. “Once the duration of testing exceeds 40 minutes, the state of consciousness is no longer considered when choosing the appropriate CPT^® code,” says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison. “Rather, the extended duration itself determines the appropriate code.”

Extended EEG: When our physician records between 41 and 60 minutes of EEG time, you choose from the extended EEG codes for 41-60 and more an hour, respectively. If the physician records between 41 and 60 minutes of EEG time, you’d report 95812 (Electroencephalogram  [EEG]  extended  monitoring;  41-60 minutes). When the EEG recording time exceeds 60 minutes, opt instead for 95813 (… greater than 1 hour).

Dismiss awake, drowsy, asleep, coma: Irrespective of the recording being done in awake/drowsy, awake/asleep, asleep/coma states, you always choose from 95812 and 95813 when your physician does an extended EEG.

Example: Notes indicate that the physician performed an awake/drowsy EEG that lasted 48 minutes. You would report 95812 for the service rather than 95816.

Step 3: Check if E/M Codes Apply

You should also do a quick check if your physician did a scheduled EEG or decided to do an EEG in a patient who underwent evaluation for a complaint in the same encounter. In the latter situation, you can report a separate E/M service. “In this circumstance, one would report the E/M service with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional  on  the  same  day  of  the  procedure  or  other  service) if the decision to perform the EEG on the same day is made during the E/M service.” Przybylski says.

Example: You may read that a patient who was operated for a brain cyst about 6 months ago reports to the physician complaining of headaches. The physician performed a problem-focused history and an expanded problem-focused exam; notes indicated low-complexity medical decision-making (MDM). Then, the physician conducted an awake/asleep EEG that lasted about 30 minutes.

In this case, you can report both the EEG as well as the E/M services. For EEG, you submit code 95819 and for the E/M service, you submit code 99213 (Office  or  other  outpatient  visit for  the  evaluation  and  management  of  an  established  patient,  which  requires  at  least  2  of  these  3  key  components:  an  expanded  problem  focused  history;  an  expanded  problem  focused  examination;  medical  decision  making  of  low  complexity…). You should append modifier 25 to 99213 to show that the E/M service was separately identifiable from the EEG service. You will also submit the diagnosis code for headache (R51, Headache).