Curious about how CPT code 95819 differs from other routine EEG codes? Let’s find out! Electroencephalography (EEG), as you may know, is a common and safe diagnostic procedure for evaluating a patient’s brain function. Talking about numbers, approximately 4.5 million EEGs are performed annually in the United States. But how many of them are coded or billed accurately on the first try?
The answer is only a few, and the reason is quite simple. The test has multiple codes due to the varying clinical circumstances and monitoring requirements. Hence, the coding confusion. Today, we will discuss the 95819 CPT code in detail so you can apply it correctly.
CPT Code 95819 – Description
CPT code 95819 refers to a standard, routine electroencephalography (EEG) procedure. It sometimes includes active procedures (provocative maneuvers for eliciting epileptic abnormalities), such as hyperventilation and photic stimulation.
So, what happens during an EEG? A technician attaches electrodes to the patient’s scalp to evaluate the brain’s electrical activity. The primary purpose of this test is to detect abnormalities, including epilepsy.
In short, this code is quite similar to CPT code 95816. The key difference is the evaluation of the patient’s brain function in distinct physiological states. To be more specific, the 95819 CPT code is applied when the patient’s brain activity is captured in the following two states:
- Awake (when the patient is alert)
- Asleep (when the patient is in light sleep)
Whereas CPT 95816 is reported when the patient’s brain activity is monitored during awake and drowsy states.
Since CPT code 95819 specifies a standard procedure, the study typically lasts around 20 to 40 minutes. Anything longer than that requires a different code.
Scenarios Where CPT Code 95819 is Applicable
Here are three detailed, applicable scenarios of this code:
Routine EEG for Seizure Evaluation
Epilepsy is fairly common in the U.S., affecting 1 in 26 people at some point in their lifetime. But how common is it in adults? According to the CDC, around 2.9 million adults in the U.S. had active epilepsy during 2021 and 2022. EEG is a common test to detect this condition.
So, now assume that a 42-year-old woman arrives at a neurology clinic with her husband, who reports witnessing a seizure while she was sleeping. During evaluation, the patient notifies the neurologist about waking up with a severe headache and vomiting after the episode. Suspecting epilepsy, the healthcare provider orders a routine EEG.
A technician sets up everything and performs the study, recording the patient’s brain activity in both awake and asleep states. He then uses CPT code 95819 with modifier TC to report the technical portion of the service.
Routine EEG for Suspected Epilepsy
Did you know healthcare providers also order an EEG if a patient has symptoms that could be a result of undiagnosed epilepsy? Let us elaborate on that! Since this condition affects both men and women equally in the U.S., let’s assume a 45-year-old man is referred to a neurologist due to his frequent fainting spells.
After a brief evaluation of the patient’s history and current condition, the neurologist orders a routine EEG. A technician performs the test and monitors the patient’s brain activity in two states: when he is awake and when asleep. The neurologist then interprets the result and uses CPT code 95819 to bill for his service.
Routine EEG to Diagnose PTE
Traumatic brain injury (TBI) is a known cause of epilepsy. There are 2.5 million cases of TBI each year in the U.S. Did you know that post-traumatic epilepsy (PTE) occurs in 15% of these TBI patients?
So, for the final example, suppose a 19-year-old cyclist sustains a moderate traumatic brain injury in an accident. He resumes his daily life after a short hospitalization. However, he starts experiencing frequent seizures seven months later.
His mother takes him to a neurologist and notifies the healthcare provider about his other symptoms as well, confusion and exhaustion. The specialist suspects PTE and orders the technician to perform a routine EEG.
The recording captures the patient’s brain activity while he is awake and during a nap. The neurologist then interprets the result, confirms PTE, and bills the service using CPT code 95819.
Applicable Modifiers for CPT Code 95819
You can apply the following modifiers with this code:
Modifier TC
Want to receive payment for your technical role in EEG? Apply modifier TC to CPT code 95819 if you only performed the test and left the interpretation to another professional.
Modifier 26
Did you only interpret an EEG and create a report? In this case, append modifier 26 to CPT code 95819. It will notify the payer that you have only performed the professional component of this diagnostic test.
Modifier 59
Was the EEG you performed distinct and separate from other services or tests provided to the same patient on the same day? You can use modifier 59 with CPT code 95819 to convey this information.
CPT Code 95819 – Billing & Reimbursement Guidelines
For a smooth billing and reimbursement process, follow these tips for CPT code 95819:
Use CPT Code 95819 Accurately
As we said earlier, it is very easy to confuse this code with the 95816 CPT code. Therefore, you must understand their key differences. Apply the 95819 CPT code only if you have recorded the patient’s electrical brain activity when he was awake and asleep. If the test was performed in any other state, use a different code.
Justify EEG’s Medical Necessity
By justifying medical necessity, we simply mean that you must maintain complete documentation. This includes recording the following details:
- Patient’s symptoms
- Clinical reason for performing the test
- Duration
- Patient’s physiological states (awake and asleep)
- Activation procedures (hyperventilation or photic stimulation)
- Interpretation
Apply Appropriate Modifiers
If the test is performed and interpreted by different people, append modifiers 26 and TC with CPT code 95819. Otherwise, leave it as it is. You can also apply other modifiers to communicate unusual circumstances.
Verify Payer Policies
Before performing and billing an EEG, check if there is a prior authorization requirement. This proactive step will help you avoid payment delays. Review and verify each payer’s coverage criteria for timely and complete reimbursements.
Summary
Can you now differentiate CPT code 95819 from other routine EEG codes? We hope that you can, since we have covered this code quite comprehensively. To summarize, the 95819 covers an EEG that records a patient’s brain wave activity while he is awake and asleep. So make sure to use it correctly. You can refer to our detailed scenarios and tips if you have any confusion.
However, if you don’t have a competent in-house billing team, let a professional file your EEG claims. Many companies, including MediBillMD, can help you receive proper reimbursements through reliable neurology billing services. So, choose the best option for your practice.
