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Payment Policy: Digital EEG Spike Analysis
Reference Number: FC.PP.011
Product Types: ALL
Last Review Date: 02/23/2024
See Important Reminder at the end of this policy for important regulatory and legal information.
Policy Overview
1
⸴
2
and Reimbursement
3
It is the policy of Fidelis Care that:
•
Digital EEG spike analysis is covered for members/enrollees with intractable epilepsy.
•
Digital EEG spike analysis is not covered for any other indication.
Coding and Modifier Information
This payment policy references Current Procedural Terminology (CPT
®
). CPT
®
is a registered
trademark of the American Medical Association. All CPT codes and descriptions are copyrighted
2023, American Medical Association. All rights reserved. CPT codes and CPT descriptions are
from the current manuals and those included herein are not intended to be all-inclusive and are
included for informational purposes only. Inclusion or exclusion of any codes in this policy does
not guarantee coverage. Providers should reference the most up-to-date sources of professional
coding guidance prior to the submission of claims for reimbursement of covered services.
CPT
Codes
Covered Procedure Codes
95957
Digital analysis of electroencephalogram (EEG) (e.g., for epileptic spike
analysis)
95718
Electroencephalogram (EEG), continuous recording, physician or other
qualified health care professional review of recorded events, analysis of
spike and seizure detection, interpretation and report, 2-12 hours of EEG
recording; with video (VEEG)
95720
Electroencephalogram (EEG), continuous recording, physician or other
qualified health care professional review of recorded events, analysis of
spike and seizure detection, each increment of greater than 12 hours, up
to 26 hours of EEG recording; interpretation and report after each 24-
hour period; with video (VEEG)
95722
Electroencephalogram (EEG), continuous recording, physician or other
qualified health care professional review of recorded events, analysis of
spike and seizure detection, interpretation, and summary report, complete
study, greater than 36 hours, up to 60 hours of EEG recording, with
video (VEEG)
1
Please note that the current policy list on the provider portal is not exhaustive. Fidelis Care may from time to time employ a vendor that applies
policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly
coded. Other policies or contract terms may further determine whether a technology, procedure or treatment is payable by Fidelis Care.
2
Please note that the corresponding policy is regarding correct coding and not medical necessity.
3
Please be advised that authorization does not guarantee reimbursement and to receive reimbursement, providers should submit a claim for
services rendered (member/enrollee eligibility should be re-confirmed at the time the service is rendered).
PAYMENT POLICY
Digital EEG Spike Analysis
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CPT
Codes
Covered Procedure Codes
95724
Electroencephalogram (EEG), continuous recording, physician or other
qualified health care professional review of recorded events, analysis of
spike and seizure detection, interpretation, and summary report, complete
study, greater than 60 hours, up to 84 hours of EEG, with video (VEEG)
95726
Electroencephalogram (EEG), continuous recording, physician or other
qualified health care professional review of recorded events, analysis of
spike and seizure detection, interpretation, and summary report, complete
study, greater than 84 hours, with video (VEEG)
ICD-10-CM Covered Diagnosis Codes
ICD-10-CM Code
Covered Diagnosis codes coverage
G40.011
Localization-related (focal) (partial) idiopathic epilepsy and epileptic
syndromes with seizures of localized onset, intractable, with status
epilepticus
G40.019
Localization-related (focal) (partial) idiopathic epilepsy and epileptic
syndromes with seizures of localized onset, intractable, without status
epilepticus
G40.111
Localization-related (focal) (partial) symptomatic epilepsy and epileptic
syndromes with simple partial seizures, intractable, with status
epilepticus
G40.119
Localization-related (focal) (partial) symptomatic epilepsy and epileptic
syndromes with simple partial seizures, intractable, without status
epilepticus
G40.211
Localization-related (focal) (partial) symptomatic epilepsy and epileptic
syndromes with complex partial seizures, intractable, with status
epilepticus
G40.219
Localization-related (focal) (partial) symptomatic epilepsy and epileptic
syndromes with complex partial seizures, intractable, without status
epilepticus
G40.311
Generalized idiopathic epilepsy and epileptic syndromes, intractable,
with status epilepticus
G40.319
Generalized idiopathic epilepsy and epileptic syndromes, intractable,
without status epilepticus
G40.411
Other generalized epilepsy and epileptic syndromes, intractable, with
status epilepticus
G40.419
Other generalized epilepsy and epileptic syndromes, intractable. without
status epilepticus
G40.803
Other epilepsy, intractable, with status epilepticus
G40.804
Other epilepsy, intractable, without status epilepticus
G40.813
Lennox-Gastaut syndrome, intractable, with status epilepticus
G40.814
Lennox-Gastaut syndrome, intractable, without status epilepticus
G40.823
Epileptic spasms, intractable, with status epilepticus
G40.824
Epileptic spasms, intractable, without status epilepticus
PAYMENT POLICY
Digital EEG Spike Analysis
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ICD-10-CM Code
Covered Diagnosis codes coverage
G40.911
Epilepsy, unspecified, intractable, with status epilepticus
G40.919
Epilepsy, unspecified, intractable, without status epilepticus
G40.A11
Absence epileptic syndrome, intractable, with status epilepticus
G40.A19
Absence epileptic syndrome, intractable, without status epilepticus
G40.B11
Juvenile myoclonic epilepsy, intractable, with status epilepticus
G40.B19
Juvenile myoclonic epilepsy, intractable without status epilepticus
G40.C11
Lafora progressive myoclonus epilepsy, intractable, with status epilepticus
G40.C19
Lafora progressive myoclonus epilepsy, intractable, without status
epilepticus
Related Documents or Resources
1.
Centers for Medicare and Medicaid Services, CMS Manual System and other CMS
publications and services.
2.
Centers for Medicare and Medicaid Services, National Correct Coding Initiative (NCCI)
publications.
3.
American Medical Association, Current Procedural Terminology (CPT
®
) and associated
publications and services.
References
1.
Current Procedural Terminology (CPT
®
)
2.
Current HCPCS Level II
3.
Current ICD-10-CM Official Code Set
4.
Moeller J, Haider HA, Hirsch LJ. Electroencephalography (EEG) in the diagnosis of seizures and
epilepsy. UpToDate. www.uptodate.com. Published January 31, 2023. Accessed August 11, 2023.
5.
American Clinical Neurophysiology Society. Guideline twelve: guidelines for long-term
monitoring for epilepsy. J Clin Neurophysiol. 2008;25(3):170 to 180.
doi:10.1097/WNP.0b013e318175d472
6.
Nuwer M. Assessment of digital EEG, quantitative EEG, and EEG brain mapping: report of the
American Academy of Neurology and the American Clinical Neurophysiology Society. Neurology.
1997;49(1):277 to 292. doi:10.1212/wnl.49.1.277
7.
Cascino GD. Surgical treatment of epilepsy in adults. UpToDate. www.uptodate.com. Published
August 03, 2023. Accessed August 11, 2023.
8.
Park CJ, Seo JH, Kim D, et al. EEG Source Imaging in Partial Epilepsy in Comparison with
Presurgical Evaluation and Magnetoencephalography. J Clin Neurol. 2015;11(4): 319–330.
doi:10.3988/jcn.2015.11.4.319
9.
Bencizky S, Rosenzweig I, Scherq M, et al. Ictal EEG source imaging in presurgical evaluation:
High agreement between analysis methods. Seizure. 2016;43:1 to 5. doi:
10.1016/j.seizure.2016.09.017
10.
Staljanssens W, Strobbe G, Van Holen R, et al. EEG source connectivity to localize the seizure
onset zone in patients with drug resistant epilepsy. Neuroimage Clin. 2017;16:689– 698. Published
2017 Sep 14. doi:10.1016/j.nicl.2017.09.011
11.
Sharma P, Scherg M, Pinborg LH, et al. Ictal and interictal electric source imaging in pre- surgical
evaluation: a prospective study. Eur J Neurol. 2018;25(9):1154 to 1160. doi: 10.1111/ene.13676.
12.
Lu Y, Yang L, Worrell GA, He B. Seizure source imaging by means of FINE spatio- temporal
dipole localization and directed transfer function in partial epilepsy patients. Clin Neurophysiol.
2012;123(7):1275 to 1283. doi:10.1016/j.clinph.2011.11.007
13.
Local coverage determination: special EEG tests (L34521). Centers for Medicare and Medicaid
Services Web site. http://www.cms.hhs.gov/mcd/search.asp. Published October 01, 2015 (revised
PAYMENT POLICY
Digital EEG Spike Analysis
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January 08, 2019). Accessed August 11, 2023.Centene Clinical Policy CP.MP.105 Digital EEG
Spike Analysis, Version 01/2024
Revision History
References reviewed, updated and reformatted. Reviewed by specialist.
Annual review. References reviewed and updated.
Annual review. Replaced all instances of “member” with
“member/enrollee.” References reviewed and updated. Reviewed by
external specialist.
Added new for 2024 ICD-10 codes G40.C11 and G40.C19 to ICD-10
coding table.
Important Reminder
For the purposes of this payment policy, “Health Plan” means a health plan that has adopted this
payment policy and that is operated or administered, in whole or in part, by Centene Management
Company, LLC, or any other of such health plan’s affiliates, as applicable.
The purpose of this payment policy is to provide a guide to payment, which is a component of the
guidelines used to assist in making coverage and payment determinations and administering
benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage and
payment determinations and the administration of benefits are subject to all terms, conditions,
exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of
coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and
applicable plan-level administrative policies and procedures.
This payment policy is effective as of the date determined by Fidelis Care. The date of posting
may not be the effective date of this payment policy. This payment policy may be subject to
applicable legal and regulatory requirements relating to provider notification. If there is a
discrepancy between the effective date of this payment policy and any applicable legal or
regulatory requirement, the requirements of law and regulation shall govern. Fidelis Care retains
the right to change, amend or withdraw this payment policy, and additional payment policies may
be developed and adopted as needed, at any time.
This payment policy does not constitute medical advice, medical treatment or medical care. It is
not intended to dictate to providers how to practice medicine. Providers are expected to exercise
professional medical judgment in providing the most appropriate care and are solely responsible
for the medical advice and treatment of members/enrollees. This payment policy is not intended
to recommend treatment for members/enrollees. Members/enrollees should consult with their
treating physician in connection with diagnosis and treatment decisions.
Providers referred to in this policy are independent contractors who exercise independent judgment
and over whom Fidelis Care has no control or right of control. Providers are not agents or
employees of Fidelis Care.
This payment policy is the property of Centene Corporation. Unauthorized copying, use, and
distribution of this payment policy or any information contained herein are strictly prohibited.
Providers, members/enrollees and their representatives are bound to the terms and conditions
expressed herein through the terms of their contracts. Where no such contract exists, providers,
members/enrollees and their representatives agree to be bound by such terms and conditions by
providing services to members/enrollees and/or submitting claims for payment for such services.
PAYMENT POLICY
Digital EEG Spike Analysis
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Note: For Medicaid members/enrollees, when state Medicaid coverage provisions conflict
with the coverage provisions in this payment policy, state Medicaid coverage provisions take
precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to
this payment policy.
Note: For Medicare members/enrollees, to ensure consistency with the Medicare National
Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable
NCDs and LCDs should be reviewed prior to applying the criteria set forth in this payment
policy. Refer to the CMS website at http://www.cms.gov for additional information.
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®
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®
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