Special Electroencephalography (DL33447) Page 1 of 23 PROPOSED/DRAFT Local Coverage Determination (LCD): Special Electroencephalography (DL33447) Close Section Navigation Jump to Section... Please Note: This view is an approximation of the CMS MCD LCD Detail page. Please Note: This is a Proposed/Draft policy. Proposed/Draft LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed/Draft LCDs are not necessarily a reflection of the current policies or practices of the contractor. Contractor Information Contractor Information Table Contractor Name Palmetto GBA Contract Number 11202 Contract Type A and B and HHH MAC Jurisdiction J - M Back to Top Proposed/Draft LCD Information Document Information Jurisdiction South Carolina Source LCD ID L33447 https://localcoverage.cms.gov/local_coverage/view/lcd_public.aspx?contractInfo=378%3a... 1/29/2016
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Special Electroencephalography (DL33447) - Palmetto GBA · Special Electroencephalography (DL33447) ... are usually readily diagnosed by routine EEG studies and history. ... patient's
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Special Electroencephalography (DL33447) Page 1 of 23
PROPOSED/DRAFT Local CoverageDetermination (LCD):Special Electroencephalography (DL33447)
Close Section Navigation Jump to Section...
Please Note: This view is an approximation of the CMS MCD LCD Detail page.
Please Note: This is a Proposed/Draft policy. Proposed/Draft LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed/Draft LCDs are not necessarily a reflection of the current policies or practices of the contractor.
Special Electroencephalography (DL33447) Page 2 of 23
Proposed/Draft LCD ID DL33447
Original ICD-9 LCD ID N/A
Proposed/Draft LCD Title Special Electroencephalography
AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright 2002-2015 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright (c) American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.
UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ("AHA"), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company.
Special Electroencephalography (DL33447) Page 3 of 23
CMS National Coverage Policy Title XVIII of the Social Security Act §1862 (a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Title XVIII of the Social Security Act §1862 (a)(7) excludes routine physical examinations.
Title XVIII of the Social Security Act §1833 (e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
42 CFR §410.28 (a)(e) Part B payment for diagnostic services
42 CFR §410.32 (d)(2) who may furnish Medicare Part B services for covered diagnostic tests
42 CFR §410.32 (a)(3)(i)(ii) and (iii) diagnostic test must be ordered by the physician treating the patient
CMS Internet-Only Manuals, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §80, requirements for diagnostic x-ray, diagnostic laboratory and other diagnostic tests.
CMS Internet-Only Manuals, Pub 100-03, Medicare National Coverage Determinations, Chapter 1, Part 2, §160.22 ambulatory EEG monitoring. Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity
ABSTRACT:
An electroencephalogram (EEG) is a diagnostic test that measures the electrical activity of the brain (brainwaves) using highly sensitive recording equipment attached to the scalp by fine electrodes. It is used to diagnose neurological conditions.
This LCD addresses EEG testing via 24 hour ambulatory cassette recording.
Ambulatory EEG should always be preceded by a routine “resting” EEG. A routine “resting” EEG is described by CPT codes 95812, 95813, 95816, 95819, 95822 or 95827 and refers to a routine EEG recording of less than a 24 hour continuous duration.
Ambulatory EEG monitoring is a diagnostic procedure for patients in whom a seizure diathesis is suspected but not defined by history, physical or resting EEG. Twenty four
Special Electroencephalography (DL33447) Page 4 of 23
hour ambulatory cassette-recorded EEGs offer the ability to record the EEG on a long-term, outpatient basis. Electrodes for at least four (4) recording channels are placed on the patient. The cassette recorder is attached to the patient’s waist or on a shoulder harness. Recorded electrical activity is analyzed by playback through an audio amplifier system and video monitors.
Ambulatory EEG monitoring may facilitate the differential diagnosis between seizures and syncopal attacks, sleep apnea, cardiac arrhythmias or hysterical episodes. The test may also allow the investigator to identify the epileptic nature of some episodic periods of disturbed consciousness, mild confusion, or peculiar behavior, where resting EEG is not conclusive. It may also allow an estimate of seizure frequency, which may at times help to evaluate the effectiveness of a drug and determine its appropriate dosage.
INDICATIONS:
• Inconclusive routine “resting” EEGs; • Experiencing episodic events where epilepsy is suspected but the history, examination, and routine EEG recordings do not resolve the diagnostic uncertainties; • Patients with confirmed epilepsy who are experiencing suspected non-epileptic events or for classification of seizure type (only ictal recordings can reliably be used to classify seizure type (or types) which is important in selecting appropriate anti-epileptic drug therapy; • Differentiating between neurological and cardiac related problems; • Adjusting anti-epileptic medication levels; • Localizing seizure focus for enhanced patient management; • Identifying and medicating absence seizures; • For suspected seizures of sleep disturbances; • Seizures which are precipitated by naturally occurring cyclic events or environmental stimuli which are not reproducible in the hospital or clinic setting.
Ambulatory monitoring, however, is not necessary to evaluate most seizures, which are usually readily diagnosed by routine EEG studies and history. 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 pre-surgical 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.
Special Electroencephalography (DL33447) Page 5 of 23
• Study of neonates or unattended, non-cooperative patients; • Localization of seizure focus/foci when the seizure symptoms and/or other EEG recordings indicate the presence of bilateral foci or rapid generalization.
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Proposed/Draft Process Information
Associated Information Documentation Requirements
Documentation supporting the medical necessity should be legible, maintained in the patient's medical record and made available to the A/B MAC upon request.
A routine “resting” EEG (as described by CPT codes 95812, 95813, 95816, 95819, 95822 or 95827) must be performed prior to performing an ambulatory continuous EEG (CPT codes 95950, 95951, 95953). A claim for the routine “resting” EEG must have been submitted to Medicare with a DOS within 1 year of the DOS of the ambulatory EEG.
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.
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. Sources of Information and Basis for Decision Chapell R, Reston J, Snyder D, et al. Management of Treatment-Resistant Epilepsy. Evidence Report/Technology Assessment No. 77 prepared by ECRI Evidence-Based Practice Center for AHRQ, AHRQ Publication 03-0028, Rockville, Md., May 2003.
Ross SD, Estok R, Chopra S, et al. Management of Newly Diagnosed Patients with Epilepsy: A Systematic Review of the Literature. Evidence Report/Technology Assessment No. 39. Prepared by MetaWorks, Inc. for AHRQ, AHRQ Publication No. 01-E038. Rockville, Md., September 2001.
Valente KD, Freitas A, Fiore LA, et al. The Diagnostic Role of Short Duration Outpatient Video-EEG Monitoring in Children. Pediatr Neurol.2003;28(4):285-291.
Special Electroencephalography (DL33447) Page 6 of 23
Hirsch LJ, Brenner RP, et al. The ACNS Subcommittee on Research Terminology for Continuous EEG Monitoring. Journal of Clinical Neurophysiology. Apr.2005; 22 (2):128-35. Open Meetings/Part B MAC Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting Type Meeting State(s) Meeting Information
02/08/2016 Open Meeting South Carolina Columbia
02/11/2016 Open Meeting North Carolina Durham
02/16/2016 Open Meeting West Virginia Charleston
02/18/2016 Open Meeting Virginia Richmond
02/08/2016 CAC Meeting South Carolina Columbia
02/11/2016 CAC Meeting North Carolina Durham
02/16/2016 CAC Meeting West Virginia Charleston
02/18/2016 CAC Meeting Virginia Richmond
Comment Period Start Date 02/08/2016 Comment Period End Date 03/24/2016 Released to Final LCD Date Not yet released. Reason for Proposed LCD Provider Education/Guidance Proposed Contact Part B Policy PO Box 100238 AG-275 Columbia, South Carolina 29202-3238 [email protected]
Special Electroencephalography (DL33447) Page 7 of 23
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.
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.
99999 Not Applicable
CPT/HCPCS Codes Group 1 Paragraph: *NOTE: A routine “resting” EEG (as described by CPT codes 95812, 95813, 95816, 95819, 95822 or 95827) must be performed prior to performing an ambulatory continuous EEG (CPT codes 95950, 95951, 95953). A claim for the routine “resting” EEG must have been submitted to Medicare with a DOS within 1 year of the DOS of the ambulatory EEG.
G04.90 Encephalitis and encephalomyelitis, unspecified
G05.3 Encephalitis and encephalomyelitis in diseases classified elsewhere
G40.001 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, with status epilepticus
G40.009 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, without status epilepticus
G40.011 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status epilepticus
G40.019 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus
G40.101 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus
G40.109 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status epilepticus
G40.111 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus
G40.119 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus
Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, with status epilepticus
Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus
Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus
Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus
Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status epilepticus
Generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus
Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus
Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus
Absence epileptic syndrome, not intractable, with status epilepticus
Absence epileptic syndrome, not intractable, without status epilepticus
Absence epileptic syndrome, intractable, with status epilepticus
Absence epileptic syndrome, intractable, without status epilepticus
Juvenile myoclonic epilepsy, not intractable, with status epilepticus
Juvenile myoclonic epilepsy, not intractable, without status epilepticus
S06.1X2D Traumatic cerebral edema with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter
S06.1X2S Traumatic cerebral edema with loss of consciousness of 31 minutes to 59 minutes, sequela
S06.1X3A Traumatic cerebral edema with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter
S06.1X3D Traumatic cerebral edema with loss of consciousness of 1 hour to 5 hours 59 minutes, subsequent encounter
S06.1X3S Traumatic cerebral edema with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela
S06.1X4A Traumatic cerebral edema with loss of consciousness of 6 hours to 24 hours, initial encounter
S06.1X4D Traumatic cerebral edema with loss of consciousness of 6 hours to 24 hours, subsequent encounter
S06.1X4S Traumatic cerebral edema with loss of consciousness of 6 hours to 24 hours, sequela
S06.1X5A Traumatic cerebral edema with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
S06.1X5D Traumatic cerebral edema with loss of consciousness greater than 24 hours with return to pre-existing conscious level, subsequent encounter
S06.1X5S Traumatic cerebral edema with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela
S06.1X6A Traumatic cerebral edema with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
S06.1X6D
Traumatic cerebral edema with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, subsequent encounter
S06.1X6S Traumatic cerebral edema with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, sequela
S06.1X7A Traumatic cerebral edema with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
S06.1X7D Traumatic cerebral edema with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, subsequent encounter
S06.1X7S Traumatic cerebral edema with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, sequela
S06.1X8A Traumatic cerebral edema with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter
S06.1X8D Traumatic cerebral edema with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, subsequent encounter
S06.1X8S Traumatic cerebral edema with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, sequela
S06.1X9A Traumatic cerebral edema with loss of consciousness of unspecified duration, initial encounter
S06.1X9D Traumatic cerebral edema with loss of consciousness of unspecified duration, subsequent encounter
S06.1X9S Traumatic cerebral edema with loss of consciousness of unspecified duration, sequela
S06.890A Other specified intracranial injury without loss of consciousness, initial encounter
S06.890D Other specified intracranial injury without loss of consciousness, subsequent encounter
S06.890S Other specified intracranial injury without loss of consciousness, sequela
S06.891A Other specified intracranial injury with loss of consciousness of 30 minutes or less, initial encounter
S06.891D Other specified intracranial injury with loss of consciousness of 30 minutes or less, subsequent encounter
S06.891S Other specified intracranial injury with loss of consciousness of 30 minutes or less, sequela
S06.892A Other specified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, initial encounter
S06.892D Other specified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter
S06.892S Other specified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, sequela
S06.893A Other specified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter
S06.893D Other specified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes, subsequent encounter
S06.893S Other specified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela
S06.894A Other specified intracranial injury with loss of consciousness of 6 hours to 24 hours, initial encounter
S06.894D Other specified intracranial injury with loss of consciousness of 6 hours to 24 hours, subsequent encounter
S06.894S Other specified intracranial injury with loss of consciousness of 6 hours to 24 hours, sequela
S06.895A Other specified intracranial injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
Special Electroencephalography (DL33447) Page 22 of 23
S06.895D Other specified intracranial injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level, subsequent encounter
S06.895S Other specified intracranial injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela
S06.896A
Other specified intracranial injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
S06.896D
Other specified intracranial injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, subsequent encounter
S06.896S Other specified intracranial injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, sequela
ICD-10 Codes that DO NOT Support Medical Necessity Group 1 Paragraph: N/A
Group 1 Codes:
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