Increase Pay Up with Proper Coding for EEG Studies



Neurology coders need to understand when it is appropriate to code signs and symptoms rather than the final diagnosis for an EEG study so that significant reimbursement is not lost. Additionally, by learning when it is and is not appropriate to bill for digital analysis, audits and costly paybacks can be dramatically avoided.

Symptom-based ICD-9 Coding


It is important to keep in mind that if a patient is referred to an EEG study to rule-out seizures and the EEG is normal, payment for it may be denied by the insurance company because they don’t accept the rule-out diagnosis.
Medicare and most third-party payers will not cover tests linked to a diagnosis that is unconfirmed due to concerns about unnecessary testing. For this reason, it is recommended coding the EEG based on the symptoms that first caused concern, not the unconfirmed possible diagnoses of seizures.
For example, a patient complains of blackouts (fainting spells). The neurologist believes they may be the result of seizures but, to test for this, performs an EEG. Because a possible or rule-out diagnosis of seizures will lead to a denial in reimbursement, the neurologist codes for the symptoms of either fainting spells (780.2) or brief loss of consciousness (780.09) along with 95819 for the awake and asleep EEG.
It is recommended to contact your local Medicare carrier and ask what justifies medical necessity. Such information can also be found by searching for local carrier policies.

Long-term Monitoring


Denials for long-term monitoring (95950-95951, 95953, 95956) usually occur due to the lack of documentation that conventional EEG studies (95816, 95819, 95822, 95827) were first performed (as per Medicare and most third-party payer guidelines). Carrier policies state that these studies must be seizure-focus in nature, meaning they are performed to track and analyze brain seizures. This must also be noted in the patient chart and any documentation.
For example, a neurology patient suffers from extended convulsive seizures, also called status epilepticus (345.3), which requires surgery. To find the exact location in the brain where the seizures originate, the neurologist performs a long-term monitoring EEG study.


Digital Analysis of EEG


Neurology coders who inappropriately bill 95957 (digital analysis of electroencephalogram [EEG] [e.g., for epileptic spike analysis]) may see added reimbursement initially, but then face demands for large paybacks and increased scrutiny during and after audits for all billing practices. The confusion stems from the incorrect belief that the use of a digital EEG machine automatically results in a digital analysis. While it is true that only a digital machine may yield the data used to create an analysis report, Digital analysis typically involves extra time for neurologist selecting specific areas of the study to analysis digitally and then spend an extra 20 to 30 minutes reviewing the extra reports.
If a practice that routinely bills for and gains reimbursement for digital analysis is audited, and a record of the additional work performed is not in the corresponding patient records, carriers will demand refunds.
Typically neurologists do not have the opportunity to perform this additional work. Digital analysis is more commonly used at specialty centers (e.g., epilepsy surgery programs).
It is recommended to contact your local Medicare carrier and ask what justifies for Digital analysis of EEG. Such information can also be found by searching for local carrier policies.
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