Neurosurgery Coding Alert

Question: The physician saw a patient he operated on six months ago for a brain cyst. The patient came in today complaining of headaches. The physician performed a problem-focused history and an expanded problem-focused exam. The notes indicated low-complexity medical decision-making (MDM). Then, the physician conducted an awake/asleep electroencephalogram (EEG) that lasted about 30 minutes. Which CPT^® codes should we report for this procedure?

Hawaii Subscriber

Answer: In this case, you can report both the electroencephalogram EEG code as well as the evaluation and management (E/M) services.

For the EEG, you will report 95819 (Electroencephalogram (EEG); including recording awake and asleep). For the E/M service, you should report 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…).

Modifier alert: You should then append 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) to 99213 to show that the E/M service was separately identifiable from the EEG service. And don’t forget to report ICD-10 code R51 (Headache) as the diagnosis for the headache.