Electroencephalography (EEG) procedures are used to measure electrical activity inside the brain. However, failure to accurately bill for these procedures can significantly strain the revenue cycle of neurology practices.
Therefore, our billing experts at MediBillMD decided to dedicate this blog to discussing all the ins and outs of billing one of the EEG procedures covered under CPT code 95816. We will explain what its descriptor entails, share clinical scenarios, list the applicable modifiers, and discuss the reimbursement guidelines.
Thus, if you want to learn all these, read this guide till the end!
CPT Code 95816 – Description
CPT 95816 is from the ‘Routine Electroencephalography (EEG) Procedures’ code range, which is maintained by the American Medical Association (AMA).
It covers EEG, which is a diagnostic test that the provider performs during the awake and drowsy states of the patient. During this procedure, the provider uses small electrodes attached to the scalp to measure the brain’s electrical activity.
Scenarios Where CPT Code 95816 is Applicable
Here are some real-world clinical scenarios to help you better gauge the full scope of CPT 95816:
Suspected New-Onset Seizure Disorder
Picture a 47-year-old patient experiencing unexplained episodes of brief staring spells and confusion. The physician orders an EEG (CPT code 95816). The findings will capture baseline brain activity while the patient is awake and look for epileptiform discharges when the patient is drowsy.
Childhood Developmental Regression Assessment
Imagine a 6-year-old boy who was previously meeting milestones, such as bladder control and speaking in multi-word sentences. He recently started showing signs of developmental regression, including increased irritability and loss of speech. The parents also reported brief moments of zoning out.
Thus, the physician orders an EEG (CPT code 95816). It captures brain activity during awake and drowsy periods to screen for subtle or non-convulsive seizure activity.
Recurrent Syncope with Atypical Features Evaluation
Consider a 19-year-old female patient who visits the clinic. She complains of experiencing recurrent fainting spells. Besides, sometimes the fainting is accompanied by brief, uncontrolled jerking movements.
The physician orders an EEG (CPT code 95816). The procedure captures brain activity when the patient is awake and drowsy. The findings help differentiate between cardiac-related syncope and subtle seizure activity.
Applicable Modifiers for CPT Code 95816
Below are all applicable modifiers for CPT 95816:
Modifier 26
If you are a physician who only interpreted the recorded electrical activity of the brain and prepared a written report, then append modifier 26 to CPT code 95816. Modifier 26 specifies the professional component of the service.
Modifier TC
Facilities, such as hospitals and diagnostic centers primarily, charge for the equipment, resources, and supplies used during the EEG. Thus, append modifier TC to CPT code 95816 to bill for the technical component of the procedure.
Modifier 76
What happens when a patient in the ICU requires EEG procedures twice on the same day and by the same neurologist to monitor seizure activity? You append modifier 76 to the second CPT code 95816 to bill for both EEGs.
CPT Code 95816 – Billing & Reimbursement Guidelines
The following are the essential billing requirements related to the EEG procedure (awake and drowsy):
Focus on Documentation Completeness
One requirement across all payers remains the same, regardless of the procedure. Following it ensures timely reimbursement. Do you want to know which one? Demonstrating the medical necessity of the rendered services through comprehensive and accurate documentation!
Therefore, when billing the EEG procedure covered under CPT code 95816, your documentation must include the following:
- Date of service.
- Details about patient symptoms.
- A clear order from a physician or other healthcare professional recommending the EEG procedure with awake and drowsy recordings.
- Documentation confirming the recording of brain activity in both awake and drowsy states.
- A written and signed report of the test that includes findings, interpretation, and clinical correlation. The report should also include the method used and the results.
- Details of the technical aspects of the EEG, such as electrode placement, duration, and details related to any activations like photic stimulation or hyperventilation.
Review Payer-Specific Guidelines
Billing and reimbursement policies often vary from payer to payer. Therefore, you should carefully review the specific billing requirements before claim submission to avoid potential denials and payment delays.
Even though CPT code 95816 covers a routine EEG service, some payers may require you to obtain pre-authorization before performing it. Besides, if the patient has recently undergone any EEGs, some payers may deny payment due to frequency limitations.
Use Appropriate Modifiers
CPT code 95816 includes both the technical and professional components of the EEG procedure. Thus, if you do not own the equipment and performed an interpretation of the findings, you should append modifier 26 to the claim.
Similarly, if you are a facility that owns the equipment and supplies used during the procedure, you should report CPT 95816 with modifier TC.
You can review more details on the appropriate modifier usage in the ‘Applicable Modifiers for CPT Code 95816’ section.
Summary
Well, that was quite a bit of information that we shared in this guide. Before concluding and saying goodbye, let’s take a quick look at all the key takeaways.
First, we explained the CPT code 95816’s descriptor. It covers the recording of the brain’s electrical activity during the awake and drowsy states of the patient.
Next, we shared a few clinical scenarios, giving a glimpse into where this CPT code applies. These include suspected new-onset seizure disorder, childhood developmental regression assessment, and recurrent syncope with atypical features evaluation.
Furthermore, we shared the list of all applicable modifiers, including TC, 26, and 76. Finally, we discussed the billing and reimbursement guidelines to help you ensure timely payment for the EEG procedure.
We understand that handling billing and coding is easier said than done. Thus, at MediBillMD, we help practices experience the ultimate financial success by outsourcing neurology billing services to our seasoned team.
