95813
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
1.63
Facility
$479.64
Non-Facility
$479.64
Documentation Required
- For claims using CPT codes not listed in this article, submit supporting clinical and billing documentation for individual review.
- A claim for the prior routine EEG must have been submitted to Medicare with a date of service within 1 year of the ambulatory EEG date of service; documentation/proof of that prior claim must be available.
- When billing only the professional or the technical component, documentation must indicate which component was provided and support billing of that single component.
- Medical necessity must be documented for outpatient ambulatory monitoring beyond 48 hours and for any additional 48-hour monitoring performed at a later date.
Key Coverage Criteria
- Ambulatory continuous EEG is covered only if a prior routine “resting” EEG was performed before the ambulatory EEG.
- Routine EEGs covered under this policy are those described by CPT codes 95812, 95813, 95816, 95819, or 95822.
- A routine EEG is defined as a recording of less than a 24-hour continuous duration.
- 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.
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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