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39.3.6 Ambulatory Electroencephalogram (A/EEG)
Epilepsy is a clinical diagnosis which, in the overwhelming majority of cases, can be characterized with a standard electroencephalogram (EEG), a detailed history, a detailed physical examination that includes a comprehensive neurological examination, and an accurate description of the patient's epileptic phenomenon (because a positive interictal pattern of the EEG does not confirm the diagnosis beyond doubt).
There are some studies that show an advantage for intensive A/EEG monitoring in some cases where it has not been possible to confirm or support a diagnosis of epilepsy or to confirm or support the differential diagnosis of epilepsy from pseudoconvulsive episodes associated with transient cerebral ischemia from variable causes other than epilepsy.
A/EEG testing is a benefit of the Texas Medicaid Program. A 24-hour A/EEG may be covered for clients in whom:
• A seizure diathesis is suspected but is not defined by history, physical examinations, or resting EEG.
•Syncope or transient ischemic attacks have not been explained by conventional studies.
The time unit for monitoring is 24 hours. Benefits are limited to three 24-hour units for each physician for the same patient in a six-month period if it is medically necessary.
A/EEG should be billed using procedure codes 5/I/T-95950, 5/I/T-95951, 5/I/T-95953, or 5/I/T-95956.
Procedure codes 5/I/T-95950, 5/I/T-95951, 5/I/T-95953, and 5/I/T-95956 are related codes. If multiple procedure codes are billed on the same day, the most inclusive code will be paid, and all other codes will be denied.
Procedure codes 5/T-95950, 5/T-95951, 5/T-95953, and 5/T-95956 are automatically payable when billed with the following International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes or their equivalent narrative description listed below.
Request for payment of codes 5/T-95950, 5/T-95951, 5/T-95953, and 5/T-95956 in any place of service without the enumerated ICD-9-CM codes or their equivalent narrative description will be denied as an inappropriate service for the diagnosis. Upon appeal to the associate medical director, codes 5/T-95950, 5/T-95951, 5/T-95953, and 5/T-95956 may be paid with other related procedure codes when the submitted documentation establishes the medical necessity of the service.
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