Special Electroencephalography (EEG) - CPT 95950, 95951, 95953

Monitoring for identification and lateralization of cerebral seizure foci by ambulatory or continuous 24-hour Electroencephalogram (EEG) may be necessary in patients where epilepsy is suspected but not confirmed by clinical manifestations or resting EEG. Ambulatory EEG (95950 or 95953) should always be preceded by an awake and sleep study (95816, 95819, 95822 or 95827). The combination of electroencephalographic and video monitoring of a patient is useful and medically necessary in the initial diagnosis of epilepsy, particularly where previous attempts to define or characterize the seizure activity have proven inconclusive. It may also be medically necessary in the differentiation of psychogenic seizures from epilepsy and in the localization of a seizure focus prior to a surgical intervention for intractable epilepsy. It is anticipated that clinical examination and routine electroencephalographic studies be utilized before employing electroencephalographic and video monitoring, and that this study be essential to the establishment of an appropriate treatment regimen. Additionally, the study may be used in pediatric Medicare beneficiaries where history and clinical descriptions of seizure activity are difficult to obtain. Medicare anticipates that many of these outpatient studies will not provide the diagnosis within the first 24 hours, but expects that 72 hours of monitoring will be diagnostic in most circumstances. Occasionally patients may require more extensive monitoring, and medical necessity must be documented for review in these circumstances. This 72-hour limitation does not apply to the inpatient setting where patients are frequently withdrawn from their anti-epileptic regimens, and where precise presurgical localization of epileptic foci is often conducted.

It is anticipated that once the diagnosis has been established, this study will not be repeated, nor will it be used in the monitoring of a therapeutic regimen. Again, this expectation will not be applied to patients readmitted for inpatient care of their seizure disorder.

Limitations:

Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

• Safe and effective.
• Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
• Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
• Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
• Furnished in a setting appropriate to the patient’s medical needs and condition.
• Ordered and furnished by qualified personnel.
• One that meets, but does not exceed, the patient’s medical need.
• At least as beneficial as an existing and available medically appropriate alternative.

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

12X, 13X, 18X, 21X, 22X, 23X, 28X, 71X, 73X, 77X, 85X

Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances, Revenue Codes are purely advisory; unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual Publication 100-04, Claims Processing Manual, for further guidance.

074X

CPT/HCPCS Codes

Note:	Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
95950©	Ambulatory EEG monitoring
95951©	EEG monitoring/videorecord
95953©	EEG monitoring/computer

ICD-9-CM Codes That Support Medical Necessity

The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 95950, 95951 and 95953:

Covered for:

300.11	Conversion disorder
345.00–345.01	Generalized nonconvulsive epilepsy
345.10–345.11	Generalized convulsive epilepsy
345.2–345.3	Epilepsy and recurrent seizures
345.40–345.41	Partial epilepsy and epileptic syndromes with complex partial seizures
345.50–345.51	Partial epilepsy and epileptic syndromes with simple partial seizures
345.70–345.71	Epilepsia partialis continua
345.80–345.81	Other forms of epilepsy and recurrent seizures
345.90–345.91	Epilepsy, unspecified
426.9	Stokes-Adams syndrome (syncope with heart block)
780.2	Syncope and collapse
780.33	Post traumatic seizures
780.39	Other convulsions

Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Diagnoses That Support Medical Necessity

N/A

ICD-9-CM Codes That DO NOT Support Medical Necessity

N/A

Diagnoses That DO NOT Support Medical Necessity

All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.

Documentation Requirements

Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.

Monitoring beyond 72 hours must be supported by written documentation for each additional 24 hours of monitoring and be made available to Medicare upon request.

Appendices

N/A

Utilization Guidelines

Medicare would not expect to see more than three services (three of one or three of any combination of services) billed in most circumstances within a one-year period.

It is anticipated that once the diagnosis has been established, this study will not be repeated, nor will it be used in the monitoring of a therapeutic regimen. As stated above, this expectation will not be applied to patients readmitted for inpatient care of their seizure disorder.

Notice: This LCD imposes utilization guideline limitations. Despite Medicare's allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services.