Coding FAQs

• Sleep Studies (95805-95811)
• Electroencephalography—Routine (95812-95827)
• Electroencephalography (EEG)—Long Term Monitoring (95950-95956)
• Electroencephalography (EEG)—Digital EEG Analysis (95957)
• Muscle and Range of Motion Testing (95831-95852)
• Electromyography (EMG) (95860-95875)
• Nerve Conduction Studies (95900-95904)
• Somatosensory Evoked Potentials
• Intraoperative Monitoring (95920)
• Autonomic Testing (95921-95923)
• Neurostimulators, Analysis-Programming (95970-95979)
• Central Nervous System Assessments/Testing (96101-96120)
• ICD-9
• Acute Stroke Coding
• Evaluation and Management

Sleep Studies

Q: What CPT® code should be used for polysomnography with CPAP?

A: CPT® code 95811 (Polysomnography; sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist) should be used for polysomnography with CPAP. Do not use a combination of CPT® 95810 and 94660 for this procedure any longer (as was done up through 1997, before code 95811 was approved).

Electroencephalography (EEG)—Routine (95812-95827)

Q: When should the extended monitoring EEG CPT® codes 95812 and 95813 be used?

A: Routine length of monitoring is now defined as lasting 20 to 40 minutes. The extended monitoring codes are to be used for monitoring times greater than 40 minutes. Code 95812 is defined as covering 41-60 min of monitoring and code 95813 is defined as covering any monitoring that is greater than one hour. Codes 95812 and 95813 can be used in place of 95816, 95819 or 95822 but are not to be billed together with them.

Q: What is the minimum number of channels or electrodes to be used in order to report codes 95812, 95813, 95955 and 95822?

A: One has to meet the minimum technical standards for an EEG test, not only with a minimum of 20 minutes of monitoring, but with a minimum of eight channels and other rules as set forth by national organizations such as the American Clinical Neurophysiology Society.

Q: What is the difference between 95816 (EEG recording including awake and drowsy) and code 95819 (EEG recording including awake and asleep)?

A: The answer is that to use 95819 the patient must have fallen asleep and if not 95816 should be used. However, the line between drowsy and asleep can often be difficult to determine and it is permissible to use 95819 if a sleep study was intended, but, despite the best efforts of the technician, sleep was not obtained.

Q: What is the purpose of video monitoring equipment on some of the new EEGs?

A: The purpose is to record what the patient was doing during the routine EEG for clinical correlation purposes. Is there an extra code to bill for an EEG with video in this situation? No - there is no extra fee or code for using the video in this context. It's still the same code as if no video.

Electroencephalography (EEG)—Long Term Monitoring (95950-95956)

Q: What do I do if the monitoring is less than 24 hours (i.e. 8 hours, 10 hours etc.)?

A: In the opinion of the American Academy of Neurology and the American Clinical Neurophysiology Society, more than half of the 24 hours of monitoring is adequate to use these codes. If the recording time is less than 12 hours, one should bill the appropriate monitoring code with modifier 52 to indicate the service was reduced in some way (as described in the CPT® book) and to indicate the actual number of hours that the study was performed. However, Principles of CPT® Coding, Fourth Edition provides a different opinion: "Video-EEG monitoring (95951) is used for prolonged monitoring of seizures. Usually, the coded procedure lasts 24 hours. Sometimes the monitoring is shorter, e.g., because the patient was off monitoring to undergo magnetic resonance imaging. When monitoring is less than 15 hours, but more than 8 hours, use modifier 52. When monitoring is less than 8 hours, use code 95813 instead of code 95951."(page 453)

Q: What is the appropriate CPT code for ambulatory EEG recordings?

A: CPT code 95950 is commonly used for ambulatory 24 hour EEG recording.

Q: What is the difference between CPT code 95953 and 95956?

A: CPT code 95953 is commonly used for simple take home digitally recorded ambulatory EEGs. CPT code 95956 is a study which is performed in a facility setting with staff present the entire time the study is performed.

Electroencephalography (EEG)—Digital EEG Analysis (95957)

Q: When should I not use Code 95957? When do I use Code 95957?

A: Code 95957 should not be used simply when the EEG was recorded digitally. There is no additional charge for turning on an automated spike and seizure detector on a routine EEG, ambulatory EEG, or video-EEG monitoring. Nor is there an additional code for performing EEG on a digital machine instead of an older generation analog machine. Some features of digital EEG make it easier and quicker to read, and other features slow it down by providing new optional tricks and tools. Overall, it is about the same amount of work as an analog EEG.

Code 95957 is used when substantial additional digital analysis was medically necessary and was performed, such as 3D dipole localization. In general, this would entail an extra hour's work by the technician to process the data from the digital EEG, and an extra 20-30 minutes of physician time to review the technician's work and review the data produced. Most practitioners would not have the opportunity to do this advanced procedure. It would be more commonly used at specialty centers, e.g. epilepsy surgery programs. Note that the codes for "monitoring for identification and lateralization of cerebral seizure focus" already include epileptic spike analysis.

Muscle and Range of Motion Testing (95831-95852)

Q: Can I bill separately for these types of procedures in addition to an office visit, consult, etc.?

A: In Principles of CPT® Coding, Fourth Edition it is stated that these codes can be billed on the same date as an evaluation and management service if the E/M service is performed as a significant, separately identifiable effort from the muscle and range of motion testing procedure performed (pages 447-448).

Electromyography (EMG) (95860-95875)

Q: How many muscles should/need to be studied per limb in order to use the limb EMG codes?

A: To bill these codes, extremity muscles innervated by three nerves (for example, radial, ulnar, median, tibial, peroneal, femoral, not sub-branches) or four spinal levels must be evaluated, with a minimum of five muscles studied per limb.

One cannot bill paraspinals separately with these codes - unless studying paraspinals between T3-T11, in which case code 95869 is to be used.

Nerve Conduction Studies

Q: What is the appropriate way to code for an inching nerve conduction velocity study?

A: Inching studies use the appropriate nerve conduction code x1 unit no matter how many segments are studied.

Somatosensory Evoked Potentials

Q: What numbers of units of codes can be used when multiple nerves or dermatomes (skin sites) are stimulated in a given limb?

A: Only one unit of 95925 can be used regardless of the number of nerves or dermatomes (skin sites) that are stimulated in each upper limb (on one or both sides). Similarly, only one unit of 95926 can be used regardless of the number of nerves or dermatomes (skin sites) that are stimulated in each lower limb (on one or both sides). Note that the codes are defined as bilateral codes. Modifier 52 must be used for unilateral studies.

Q: Can these codes (95925-95930) be reported together?

A: The answer is yes. Physicians have asked how many peripheral nerves or skin sites must be tested in order to bill the codes (95925-27)—the answer is two—one stimulation site on each upper (95925) or lower (95926) limb or on each side of the trunk or head (95927).

Intraoperative Monitoring (95920)

Q: How do I account for the time appropriately when billing code 95920 (intraoperative testing)?

A: This code is billed along with the code for the particular evoked potential or other neurodiagnostic test that is being performed intraoperatively. The evoked potential code or other procedure code covers the usual baseline test time of 20-60 minutes and one adds one unit of code 95920 for each additional 60 minutes of monitoring beyond what is normally done. Regardless of the location of the monitoring physician, modifier 26 would always be used when reporting these services.

Autonomic Testing (95921-95923)

Q: Can any of these codes be billed more than one time for tests performed on a single patient on the same date? And can codes 95921-95923 be reported together?

A: The answer is no and yes respectively. There are many reimbursement problems for these tests across the country - many payers, including some Medicare carriers, still consider them to be "investigational."

Neurostimulators, Analysis-Programming (95970-95979)

Q: When is time a factor in reporting these procedures?

A: For complex cranial neurostimulation, billing is always time-based. Code 95974 is used to report programming and intraoperative (at initial insertion/revision) or subsequent electronic analysis of an implanted complex cranial nerve neurostimulator. 95975 is used to report each additional 30 minutes after the first hour.

For brain, spinal cord, and other peripheral neurostimulation, billing is time-based if the device qualifies as complex.

For purposes of reporting these codes, time includes but is not limited to face-to-face time spent with the patient. It includes time spent on the floor or unit after adjusting the programming, waiting for the patient to respond and to monitor for side effects.

Q: When is time not a factor?

A: Time is not a factor in programming and analysis of a simple neurostimulator (95971). Nor is time a factor in reporting analysis of a previously-implanted simple or complex neurostimulator without re-programming (95970).

Q: What is the difference between a simple and complex neurostimulator?

A: The number of features it is capable of affecting. In CPT® 2002, the notes were updated to reflect assessment capabilities and types of analyses performed using current neurostimulator technology, making all thalamic deep brain stimulator reprogramming complex. A simple neurostimulator is capable of affecting three or fewer of the following; a complex neurostimulator is capable of affecting more than three:

• pulse amplitude
• pulse duration
• pulse frequency
• 8 or more electrode contacts
• cycling
• stimulation train duration
• train spacing
• number of programs
• number of channels
• alternating electrode polarities
• dose time (stimulation parameters changing in the time periods of minutes including dose lockout time)
• more than 1 clinical feature (e.g., rigidity, dyskinesia, tremor)

Central Nervous System Assessments/Tests (96101-96120)

Q: Can a physician bill for code 96116?

A: Yes, a physician should use this code when doing extended neurobehavior exams on patients. Some rules apply:

• The code is based on time. Time taken must be mentioned explicitly in the report.
• The code is for an hour of Neurobehavioral testing. The total time is the sum of time taken to administer, to score, and to generate a report.
• There must be a separately identifiable report.

Q: 96116 is a per hour code. How do I bill the service if I spend less than an hour?

A: If 31 minutes or more are spent on the service, you can bill 96116. This includes time spent face-to-face with the patient, interpreting test results, and preparing the report. The total time must be mentioned explicitly in the report.

Q: Can I bill an E/M on the same day as 96116?

A: Yes, the work for the testing and the E/M service need to be documented. The reports need either to be separate, or else at least a separately identifiable portion of a combined E/M-Neurobehavior testing report.

Q: If so, do I need to use a modifier?

A: A modifier -25 should not be necessary to report an E/M service on the same day as 96116, however some carriers may reject if it is not attached to the E/M code.

Q: Can I use 96116 to report a MMSE?

A: A mini-mental status exam can be part of the Neurobehavioral testing, though a mini-mental status exam by itself is not reportable using 96116. Mini-mental status exams, when done without additional Neurobehavioral testing, are considered part of the evaluation and management service and should be reported with the appropriate E&M code. When the MMSE is done as part of more extensive Neurobehavioral testing as described above, you may report 96116.

Q: Neuropsychological testing is done for epilepsy and Parkinson patients in preparation for surgery. The neuropsychologist conducts some of the tests themselves, for other tests a technician administers the tests while they observe. The neuropsychologist then interprets the results of all the tests and writes their report. Can we can bill for both the doctor's time as well as the technician's time if both are present with the patient at the same time for codes 96118 and 96119?

A: The MD and the PhD may be considered interchangeable in the coding, and could be aggregated. If the tech did part of the test, and the MD or PhD did a different part of the test administration, then perhaps both the 96118 and 96119 would be billed. The local carrier should be consulted prior to billing in this manner to check on coverage policies and correct coding edits prohibiting this.

ICD-9

Q: What is the appropriate code for Mild Cognitive Impairment?

A: In 2007 a new code was introduced to specifically code for this condition; 331.83 Mild cognitive impairment, so stated.

Acute Stroke

Q: What is the appropriate way to code for the administration of t-PA?

A: Critical Care CPT® codes can be used for managing an unstable, critically ill stroke patient. The progress or admitting note must mention the time spent that day, and should state that the patient is "unstable, critically ill." We recommend that the latter is an explicit statement in the Impression.

Evaluation and Management

Q: When is time a factor in determining the coding level of the usual evaluation and management services (new and established patient office visits, consultations and hospital follow-ups)?

A: When counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter, then time, rather than elements of history, physical examination and medical decision-making, is the key controlling factor in the level of evaluation and management service determination. The definition of each evaluation and management code lists its typical time. The total length of time of the encounter should be documented and the medical record should describe the counseling and/or activities to coordinate care. The definition of "time" differs in outpatient and inpatient settings: face-to-face time: office and other outpatient visits and office consultations, unit/floor time: hospital observation services, inpatient hospital care, initial and follow-up hospital consultations, nursing facility.

Q: How do I code for extended evaluation and management services where counseling and coordination does not comprise a majority of the visit?

A: In this case the use of prolonged services codes would be appropriate. These codes involve direct patient contact that is beyond the typical time for an evaluation and management service, and can be reported in addition to the evaluation and management code. You must document the reason for the prolonged service in the patient record to account for the use of these codes. There are different sets of codes for inpatient and outpatient settings. Each set includes a code for the first hour of prolonged services and another code for each additional 30 minutes.

Q: In what other situation would time be a consideration in coding for evaluation and management?

A: The critical care codes are another instance in which coding is based on the amount of time of service. Critical care codes account for the time spent at the bedside or on the unit delivering care to a critically ill or injured patient. They can be reported in addition to an evaluation and management code. One code is for critical care during the first 30-74 minutes; another code is for each additional 30 minutes of critical care. The time does not need to be continuous and should be reported based on the total hours of care delivered in a 24-hour period.