95812
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
1.08
Facility
$383.11
Non-Facility
$383.11
Documentation Required
- Medical necessity must be documented for outpatient ambulatory monitoring beyond 48 hours and for any additional 48-hour monitoring performed at a later date.
- Documentation of history, physical examination, and prior routine EEG results supporting the indication for ambulatory EEG should be available for review (medical necessity review may be undertaken).
- Retain and provide copies of hard-copy output with analysis of all data (including bidirectional vascular flow or imaging when provided) in the patient record.
- Document clinical findings (e.g., signs/symptoms) and clinical decision rules (Wells score) supporting the medical necessity for the ultrasound.
Key Coverage Criteria
- Ambulatory EEG is indicated when a seizure diathesis is suspected but not defined by history, physical exam, or routine resting EEG.
- Ambulatory EEG is indicated when routine (resting) EEG results are inconclusive for diagnosis.
- Ambulatory EEG is indicated for patients with episodic events where epilepsy is suspected but history, examination, and routine EEG do not resolve diagnostic uncertainty.
- Ambulatory EEG is indicated in patients with confirmed epilepsy who are experiencing suspected non-epileptic events or when ictal recordings are needed to classify seizure type for therapeutic selection.
- Ambulatory EEG is indicated to differentiate between seizures and non-neurological causes such as syncopal attacks, sleep apnea, cardiac arrhythmias, or psychiatric (hysterical/psychogenic) episodes.
- Ambulatory EEG is indicated to localize a seizure focus when localization is needed for enhanced patient management.
20 Active Policies
L33693 — Peripheral Venous Ultrasound
J09
L37371 — Electroretinography (ERG)
J12
A53252 — Billing and Coding: Independent Diagnostic Testing Facility (IDTF)
J12
L35007 — Vestibular and Audiologic Function Studies
J12
L35434 — Oximetry Services
Related Codes
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