The New CPT Codes for Video-EEG

From time to time, the American Medical Association (AMA) and the Center for Medicare and Medicaid Services (CMS) review and revise the Current Procedural Terminology (CPT) codes. Over time, this process evaluates coding for all medical, surgical, and diagnostic procedures. Along with this code review, the AMA-CMS Relative Value Update Committee (RUC) reviews and resets the relative value units (RVUs) associated with the codes.

Such a periodic review was conducted recently for EEG monitoring codes. This is the code family that includes EEG done in the epilepsy monitoring unit (EMU) or intensive care unit (ICU) and ambulatory EEG monitoring. The review included both video-EEG and EEG monitoring without video. Representatives from several medical societies were deeply involved with these review stages. Commercial industry and the technologist society also participated actively in reviewing the services. Altogether, this was a deep dive into the services, and how they should be restructured.

To better identify the exact service provided, professional and technical services were separated into different code sets. This is different than how most neurodiagnostic codes are used, so familiarity with this new code set will take some time and practice. This article is meant to aid in that learning.

How New Codes Were Developed

Physician RUC survey results were used to set codes for physician work RVUs. This survey included a wide group of physicians from the National Association of Epilepsy Centers, the American Clinical Neurophysiology Society, and the American Academy of Neurology’s Epilepsy and Clinical Neurophysiology Sections. The physician RUC survey estimated the typical time taken by a physician for each service and the work intensity compared to other typical services.

The ASET Neurodiagnostic Society gave input and a survey to evaluate the technical components for each service. Industry representatives contributed details about how the services are provided. These technical components inputs included technologist staffing, supplies, and equipment for each type of service. Inputs were provided to CMS to calculate RVUs appropriate for the technical component of the services.

Some existing EEG monitoring codes had not been reviewed for more than 2 decades. In the meantime, many of those services have become more efficiently provided, and the typical patient is more easily tested. No longer does the typical patient have depth-electrode EEG with 150 channels, risk of bleeding from the depth electrodes, and use of EEG results for surgical decisions. Technologists monitoring screens for seizures are trained to watch more patients now than 25 years ago. Efficiencies in the current generation of services, compared with 25 years ago, result in lower expenses per typical patient. Because of these advances over time and efficiencies, RVUs are expected to be lower.

Codes Being Replaced

The new codes will be effective in January 2020. These replace existing EEG Monitoring codes used for limited electrode set (95950), daily video-EEG (95951), ambulatory EEG (95953), and daily EEG without video (95956).

New Physician Codes

The physician codes describe different degrees and duration of services and separate whether video is included with the EEG service. Different codes describe monitoring for a partial day, a full day, and for 2, 3, or 4 or more days. These new codes are given in Table 1.

The full-day codes require daily record review and chart notes, conducted in real time with chart notes after each day’s service. These are typically used for the daily EMU and ICU monitoring services. These may be used for 1-day ambulatory studies. The 6 multiple-day study codes typically are used for ambulatory recordings in which the record is interpreted, and the note is made after the several-day recording has been completed. Each code includes record review, analysis of automated spike and seizure detections, and any trending used for ICU EEG monitoring. A service stretching over many days may use full day codes with review and chart notes daily. In that case, a final summary report is expected at the end of the multi-day recording (eg, for monitoring EEG in the EMU or ICU).

The partial day code may be used together with any other codes. For an EMU service that is 30 hours long, a full-day code is used for 1 day’s service and a partial-day code is used for the remaining time—coded on different calendar dates.

The proposed physician work RVUs (wRVUs) are lower than for the current codes 95950 through 95956. This reflects the efficiencies that exist now compared to the wRVUs used for the past 25 years. These changes are based on the recent RUC surveys of time and intensity as reported by the physician community. The RUC survey physicians reported time and intensity of work for the EEG services, and CMS used those numbers to set work RVUs. Some old and new RVUs are presented in Table 2.

New Technical Codes:

The new technical component codes separate the services in several ways. A new code, 95700, is for electrode application and related service initiation. Beyond the set-up code, 3 dimensions define code details. The first dimension identifies whether or not the service uses video with the EEG. The second dimension defines whether the code is for a full 24-hour day or for a 2- to 12-hour partial day’s service. A third dimension identifies a technologist’s attention to monitoring during recording.

In the attention dimension, 3 levels of service are possible. In the greatest-attention code set, a monitoring technologist continuously watches up to 4 patients. In the intermediate-attention code set, a monitoring technologist intermittently checks into the recording, defined as checking the recording for a few minutes at least once every 2 hours and monitoring up to 12 patients per technologist.

The unmonitored-attention code set applies to services in which:

1. No monitoring technologist watches the signals during recording,

2. A monitoring technologist watches more than 12 recordings at a time, or

3. A monitoring technologist checks the recordings less than once every 2 hours.

Using the New Codes in Practice

Comparisons to the existing Technical Component RVUs is difficult because of the multiplicity of new codes and the absence of a current Technical Component RVU for the commonly used current code 95951. The new codes’ CPT numbers are given in Table 3.

Physician codes have specific values for ambulatory services over several days. Technical Component codes are used daily. For example, a 72-hour unmonitored ambulatory video-EEG would be coded as 95724 for the physician’s work, 95700 for the electrode set-up, and 3 technical units of 95708—1 unit coded for each day of monitoring. Another example is a 5-day EMU stay with technologists monitoring a few patients continuously and physicians who read and report the monitoring every day as well as provide daily patient-care visits. In this case, codes for the physician’s work for an initial day hospital visit (99222), 3 daily inpatient follow-up visits (99232), a discharge-day note (99238), and 5 video-EEG monitoring days (95720) would be coded. The technical codes are the set-up code on day 1 (95700), and 5 units of (95716). Those physician and technical video-EEG CPT codes (95720 and 95716) are used once each day for the 5 days of the EMU stay.

Conclusion

Implementation of the new codes, which differ substantially from existing codes, will require adjustments by all users. The RVU reductions will affect financial planning and status of physicians and laboratories and require attention to detail for both. Further details are enumerated in the book CPT 2020 published by AMA.¹