Local Coverage Determination (LCD)

Special Electroencephalography

L33447

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L33447
Original ICD-9 LCD ID
Not Applicable
LCD Title
Special Electroencephalography
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL33447
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 03/16/2023
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
12/22/2016
Notice Period End Date
02/05/2017
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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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.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Issue

Issue Description

This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity.

Issue - Explanation of Change Between Proposed LCD and Final LCD

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.

42 CFR §410.28(a) and (e) addresses Part B payment for diagnostic services.

42 CFR §410.32(b)(3)(i), (ii) and (iii) states that diagnostic tests must be ordered by the physician treating the patient.

42 CFR §410.32(d)(1) addresses who may furnish Medicare Part B services for covered diagnostic tests.

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 6, §20.4.4 Coverage of Outpatient Diagnostic Services Furnished on or After January 1, 2010

CMS Internet-Only Manual, 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 (NCD) Manual, Chapter 1, Part 2, §160.22 Ambulatory EEG Monitoring

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

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 Local Coverage Determination (LCD) addresses EEG testing via 24 hour ambulatory recording.

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 hour ambulatory recorded EEGs offer the ability to record the EEG on a long-term, outpatient basis. Recorded electrical activity is analyzed by playback through an audio system and/or 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(s)), which is important in selecting appropriate anti-epileptic drug therapy
• Differentiating between neurological, cardiac, and psychiatric related problems
• 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 48 hours of monitoring will be diagnostic in most circumstances. Ambulatory monitoring beyond 48 hours frequently produces poor data in the period after 48 hours, as electrode contact may no longer be optimal after 48 hours. Occasionally, patients may require an additional 48 hour monitoring period to establish a diagnosis, which is usually performed at a later date. Medical necessity must be documented for review in these circumstances. This 48 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 for the same diagnosis, 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 (NON-COVERED INDICATIONS):

• Study of neonates or unattended, non-cooperative patients
• Localization of seizure focus or foci when the seizure symptoms and/or other EEG recordings indicate the presence of bilateral foci or rapid generalization

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General 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.

Monitoring beyond 48 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 3 services (3 of a single or 3 of any combination of services) billed in most circumstances within a 1-year period.

It is anticipated that once the diagnosis has been established, this study will not be repeated for the same diagnosis, 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

N/A

Bibliography

Chapell R, Reston J, Snyder D, et al. Management of treatment-resistant epilepsy. Evid Rep Technol Assess (Summ). 2003;(77):1-8.

Hirsch LJ, Brenner RP, Drislane FW, et al. The ACNS subcommittee on research terminology for continuous EEG monitoring: Proposed standardized terminology for rhythmic and periodic EEG patterns encountered in critically ill patients. J Clin Neurophysiol. 2005;22(2):128-135.

Ross SD, Estok R, Chopra S, French J. Management of newly diagnosed patients with epilepsy: A systematic review of the literature. Evid Rep Technol Assess (Summ). 2001;(39):1-3.

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.

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
03/16/2023 R16

Under CMS National Coverage Policy corrected the following regulations: 42 CFR from §410.28(a)(e) to §410.28(a) and (e), 42 CFR from §410.32(a)(3)(i)(ii) and (iii) to 42 CFR from §410.32(b)(3)(i), (ii) and (iii) and 42 CFR from §410.32(d)(2) to §410.32(d)(1) and updated section headings. Under Bibliography changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and typographical errors were corrected throughout the LCD.

  • Provider Education/Guidance
  • Typographical Error
03/11/2021 R15

Under CMS National Coverage Policy added regulations 42 CFR §410.28(a)(e), 42 CFR §410.32(a)(3)(i)(ii) and (iii), CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §80, CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 6, §20.4.4 and CMS Internet-Only Manuals, Pub. 100-03, Medicare National Coverage Determinations, Chapter 1, Part 2, §160.22. Under Bibliography changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and typographical errors were corrected throughout the LCD.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
10/24/2019 R14

This LCD is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of this LCD and placed in the related Billing and Coding: Special Electroencephalography A56771 article. Formatting, punctuation and typographical errors were corrected throughout the LCD.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

  • Provider Education/Guidance
08/01/2019 R13

Under Coverage Indications, Limitations and/or Medical Necessity the verbiage “Ambulatory EEG should always be preceded by a routine EEG. A routine EEG is described by Current Procedural Terminology (CPT) codes 95812, 95813, 95816, 95819, 95822 or 95827 and refers to a routine EEG recording of less than a 24 hour continuous duration” has been removed. All coding located in the Coding Information section has been moved into the related Billing and Coding: Special Electroencephalography A56771 article and removed from the LCD. Under Associated Information Documentation Requirements the verbiage “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 code 95953). A claim for the routine EEG must have been submitted to Medicare with a DOS within 1 year of the DOS of the ambulatory EEG” has been removed. Under Bibliography changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and typographical errors were corrected throughout the LCD.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
05/31/2018 R12

Under Coverage Indications, Limitations and/or Medical Necessity second paragraph added the verbiage “Local Coverage Determination” in front of the acronym “LCD” and in the third paragraph added the verbiage “Current Procedural Terminology” in front of the acronym “CPT”. Under CPT/HCPCS Codes added the verbiage “date of service” in front of the acronym “DOS”. Under Bibliography changes were made to citations to reflect AMA citation guidelines. Typographical and punctuation errors were corrected throughout the policy.

 At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  

 

  • Provider Education/Guidance
  • Public Education/Guidance
02/26/2018 R11 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
10/01/2017 R10

Under ICD-10 Codes that Support Medical Necessity deleted ICD-10 codes S06.1X7S and S06.1X8S. These revisions are due to the 2017 Annual ICD-10 Updates.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy. 

 

  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
06/01/2017 R9

Under Sources of Information and Basis for Decision - updated titles to sources listed.

  • Provider Education/Guidance
  • Typographical Error
02/06/2017 R8 No comments were received from the provider community; therefore, no revisions were made.
  • Provider Education/Guidance
10/01/2016 R7 Under Coverage Indications, Limitations and/or Medical Necessity removed cassette and amplifier and the sentence referring to electrodes for at least four (4) recording channels. Under ICD-10 Codes That Support Medical Necessity added ICD-10 codes A92.5 and I60.2 and deleted I60.21 and I60.22. This revision is due to the Annual ICD-10 Code Update and becomes effective 10/1/16.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
09/26/2016 R6 Under CPT/HCPCS Codes Group 1: Codes deleted 95812, 95813, 95816, 95819, 95822 and 95827.
  • Provider Education/Guidance
  • Revisions Due To CPT/HCPCS Code Changes
07/25/2016 R5 Under Coverage Indications, Limitations and/or Medical Necessity removed "resting" from the description of a baseline EEG, added psychiatric related problems, removed adjusting anti epileptic medication levels, changed the time frame for ambulatory EEGs and added that the study will not be repeated for the same diagnosis. Under Associated Information- Documentation Requirements removed CPT codes 95950 and 95951, "resting", and changed 72 hours to 48 hours. Under Associated Information- Utilization Guidelinesadded that the study will not be repeated for the same diagnosis. Under CPT/HCPCS Codes Group 1: Paragraph removed CPT codes 95950 and 95951 and "resting". Under CPT/HCPCS Codes Group 1: Codes removed CPT codes 95950 and 95951.
  • Provider Education/Guidance
  • Revisions Due To CPT/HCPCS Code Changes
02/04/2016 R4 Under Coverage Indications, Limitations and/or Medical Necessity deleted CPT code 95951 from the second sentence of the first paragraph as the code was inadvertently added to the LCD. Palmetto GBA plans to allow for a comment and notice period prior to the inclusion of CPT code 95951 in the first paragraph under Coverage Indications, Limitations and/or Medical Necessity .
  • Provider Education/Guidance
  • Other
01/28/2016 R3 Under Coverage Indications, Limitations and/or Medical Necessity added 95951 to the Ambulatory EEG requirements of the first paragraph.
  • Provider Education/Guidance
  • Public Education/Guidance
  • Typographical Error
10/01/2015 R2
Under ICD-10 Codes that Support Medical Necessity changed reference to ICD-9 to ICD-10.
Under ICD-10 Codes that Support Medical Necessity added the following codes: A17.82,
A39.81, A42.82, A50.42, A52.14, A83.0, A83.1, A83.2, A83.3, A83.4, A83.5, A83.8, A83.9, A84.0, A84.1, A84.8, A84.9, A85.0, A85.1, A85.2, A85.8, A92.2, A92.31, B01.11, B02.0, B05.0, B06.01, B10.01, B10.09, B26.2, B94.1, R40.20, G04.00, G04.01, G04.02, G04.30, G04.31, G04.81, G04.90
G05.3, G92, G93.5, G93.6, H55.00, I60.01, I60.02, I60.11, I60.12, I60.21, I60.22, I60.31, I60.32, I60.4, I60.51, I60.52, I60.6, I60.8
I60.9, I61.0, I61.1, I61.2, I61.3, I61.4, I61.5, I61.6, I61.8, I62.9, I67.1, R00.0, R06.81, R25.1, R25.1, R25.2, R25.3, R25.8, R25.8
R25.9, R29.90, R40.0, R40.1, R40.2110, R40.2111, R40.2112, R40.2113, R40.2114, R40.2120, R40.2121, R40.2122, R40.2123, R40.2124, R40.2210, R40.2211, R40.2212, R40.2213, R40.2214, R40.2220, R40.2221, R40.2222, R40.2223, R40.2224, R40.2310, R40.2311, R40.2312, R40.2313, R40.2314, R40.2320, R40.2321, R40.2322, R40.2323, R40.2324, R40.2340, R40.2341, R40.2342, R40.2343, R40.2344, R40.2350, R40.2351, R40.2352, R40.2353, R40.2354, R40.2361, R40.2362, R40.2363, R40.2364, R41.0, R41.82, R45.1, R47.01, R56.9, S06.1X0A, S06.1X0D, S06.1X0S, S06.1X1A, S06.1X1D, S06.1X1S, S06.1X2A, S06.1X2D, S06.1X2S, S06.1X3A, S06.1X3D, S06.1X3S, S06.1X4A, S06.1X4D, S06.1X4S, S06.1X5A, S06.1X5D, S06.1X5S, S06.1X6A, S06.1X6D, S06.1X6S, S06.1X7A, S06.1X7D, S06.1X7S, S06.1X8A, S06.1X8D, S06.1X8S, S06.1X9A, S06.1X9D, S06.1X9S, S06.890A, S06.890D, S06.890S, S06.891A, S06.891D, S06.891S, S06.892A, S06.892D, S06.892S, S06.893A, S06.893D, S06.893S, S06.894A, S06.894D ,S06.894S, S06.895A, S06.895D, S06.895S, S06.896A, S06.896D, S06.896S
  • Reconsideration Request
  • Other (Annual Validation)
10/01/2015 R1 Under CMS National Coverage Policy, corrected Pub. 100-02, Ch. 15, Section 231 to Section 80, requirements for diagnostic x-ray, diagnostic laboratory and other diagnostic tests. Added CMS Internet-Only Manuals, Pub. 100-03, Medicare National Coverage Determinations, Ch. 1, Part 2, Section 160.22, ambulatory EEG monitoring. Under Sources of Information and Basis for Decision removed bibliography Cascino, G.D. “Video-EEG Monitoring in Adults,” Epilepsia. 2002; 43 Suppl. 3: pp. 80-93, as this article was not obtainable.
  • Provider Education/Guidance
  • Typographical Error
N/A

Associated Documents

Attachments
N/A
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
03/07/2023 03/16/2023 - N/A Currently in Effect You are here
03/02/2021 03/11/2021 - 03/15/2023 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Special Electroencephalography
  • EEG

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