95716
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- The patient's medical record must contain documentation that fully supports medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
- For diagnostic tests, report the test result on the claim if known; if the result is not known, report the symptoms that prompted the test.
- Written documentation supporting each additional 24 hours of monitoring beyond 72 hours must be made available to Medicare upon request.
Key Coverage Criteria
- Ambulatory EEG is covered for diagnostic evaluation when seeking to detect clinical seizures or interictal epileptiform activity.
- Ambulatory EEG is covered for pre-surgical evaluation to localize seizure onset when capture of multiple seizures is needed for surgical planning.
- Ambulatory EEG is covered for routine follow-up monitoring of known seizure disorder or previously identified epileptiform activity.
- Special EEG tests are covered only when they meet the reasonable and necessary requirements described in Local Coverage Determination (LCD) L34521.
- An IDTF must be credentialed and approved by Palmetto GBA provider enrollment to bill Medicare for a specific diagnostic procedure or material.
- Additional services and supplies (e.g., radiopharmaceuticals, special contrast agents, medications) are payable to an IDTF when the diagnostic test itself is payable and the supplies are commonly separately reimbursed to a physician in an office setting.
17 Active Policies
A57030 — Billing and Coding: EEG Ambulatory Monitoring
J06
L33399 — EEG Ambulatory Monitoring
J06
L33693 — Peripheral Venous Ultrasound
J09
A57667 — Billing and Coding: Special EEG Tests
J09
L34521 — Special EEG Tests
Related Codes
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