Coding Epilepsy and Seizures

Epilepsy is a common neurological disorder marked by recurrent, unprovoked seizures. Although the two terms are often used interchangeably, a seizure is a single occurrence and is different from epilepsy, which constitutes two or more unprovoked seizures. November is National Epilepsy Awareness Month and now is a great time for neurology practices and medical coding companies to brush up on epilepsy and seizure coding.

Epilepsy and Seizures

The International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE) define epilepsy as a brain disorder characterized by “an enduring predisposition to generate epileptic seizures and by the neurobiologic, cognitive, psychological, and social consequences of this condition”. Epilepsy affects both males and females of all ages, races and ethnic backgrounds. The disorder can develop from brain injury, stroke, brain cancer, and drug or alcohol abuse, though the cause of disorder in many patients may be unknown.

The John Hopkins Epilepsy Center defines a seizure as “a sudden, electrical discharge in the brain causing alterations in behavior, sensation, or consciousness”. Excessive and abnormal cortical nerve cell activity in the brain causes seizures. Seizures are classified as generalized and partial. Generalized seizures are seizures that appear to begin everywhere in the brain at once. There are 6 main types of generalized seizures: Tonic-clonic, Tonic, Clonic, Myoclonic, Absence, and Atonic. Seizures beginning in one location of the brain are termed partial seizures.

The diagnosis of epilepsy generally requires the occurrence of at least two unprovoked seizures.

Status Epilepticus

Status epilepticus (SE) is a medical emergency where the brain is in a state of persistent seizure. It is now defined in terms of specific time points for when to treat SE or when long-term side effects or complications were likely to begin, according to HealthLine. The definition of SE as published in the journal Epliepsia in 2015 is: “a condition resulting either from the failure of the mechanisms responsible for seizure termination or from the initiation of mechanisms, which lead to abnormally, prolonged seizures (after time point t1). It is a condition, which can have long-term consequences (after time point t2), including neuronal death, neuronal injury, and alteration of neuronal networks, depending on the type and duration of seizures.”

Symptoms of Epilepsy

Epilepsy signs and symptoms vary depending on the type of seizure and may include:

• Temporary confusion
• A staring spell
• Uncontrollable jerking movements of the arms and legs
• Loss of consciousness or awareness
• Psychic symptoms such as fear, anxiety or deja vu

As a person with epilepsy will usually experience the same type of seizure each time, the symptoms will be similar from episode to episode.

Diagnosis and Treatment

Epilepsy is diagnosed through neurological exams, blood tests and tests to detect brain abnormalities such as Electroencephalogram (E, EG), high-density EEG, computerized tomography (CT) scan, magnetic resonance imaging (MRI), positron emission tomography (PET), single-photon emission computerized tomography (SPECT), neuropsychological tests and certain analysis techniques to help identify the origin of the brain seizures.

Epilepsy is initially treated with medication. If medications fail to control seizures, physicians will propose surgery or other types of treatment. Epilepsy surgery involves removing the area of your brain that is causing the seizures. Other treatment options include vagus nerve stimulation, ketogenic diet, and deep brain stimulation.

Intractable epilepsy is disorder in which seizures fail to come under control with treatment. These seizures are also called “uncontrolled” or “refractory.”

Coding Epilepsy

The ICD-10 codes for epilepsy are available under G00-G99 Diseases of the nervous system, G40-G47 Episodic and paroxysmal disorders. The code descriptions include intractable or not intractable, as well as with and without status epilepticus.

• G40 Epilepsy
  • 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 seizure, intractable, with status epilepticus
  • G40.219 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus
  • G40.3 Generalized idiopathic epilepsy and epileptic syndrome
  • G40.4 Other generalized epilepsy and epileptic syndromesc
  • G40.5 Special epileptic syndromes d
  • G40.6 Grand mal seizures, unspecified (with or without petit mal)
  • G40.7 Petit mal, unspecified, without grand mal seizures
  • G40.8 Other epilepsy
  • G40.9 Epilepsy, unspecified
• G41 Status epilepticus
  • G41.0 grand mal status epilepticus
  • G41.1 Petit mal status epilepticus
  • G41.2 Complex partial status epilepticus
  • G41.8 Other status epilepticus
  • G41.9 Status epilepticus, unspecified

Coding for Epilepsy and Seizure Management

Insurance companies may cover epilepsy exams/tests, treatments, medicines, and surgeries that are clearly documented as medically necessary. Aetna, for example, covers the following CPT codes for epilepsy surgery, vagus nerve electrical stimulators, EEG video monitoring, and deep brain stimulation if selection criteria are met.

Epilepsy surgery CPT codes

• 61534 Craniotomy with elevation of bone flap; for excision of epileptogenic focus without electrocorticography during surgery
• 61536 for excision of epileptic focus, with electrocorticography during surgery
• 61537 for lobectomy, temporal lobe, without electrocorticography during surgery
• 61538 for lobectomy with electrocorticography during surgery, temporal lobe
• 61541 for transection of corpus callosum
• 61543 for partial or subtotal hemispherectomy
• 61566 Craniotomy with elevation of bone flap; for selective amygdalohippocampectomy
• 95958 Wada activation test for hemispheric function, including electroencephalographic (EEG) monitoring

CPT codes for vagus nerve electrical stimulators

Some of the CPT codes that Aetna covers if selection criteria are met for vagus nerve electrical stimulators are:

• 61885 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array
• 64553 Percutaneous implantation of neurostimulator electrodes; cranial nerve
• 64568 Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator
• 64569 Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to existing pulse generator
• 64570 Removal of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator
• 95970 Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple or complex brain, spinal cord, or peripheral (i.e., cranial nerve, peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, without reprogramming
• 95974 Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour
• + 95975 complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)

EEG video monitoring

CPT codes covered by Aetna if selection criteria are met include:

95951 Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, combined electroencephalographic (EEG) and video recording and interpretation (e.g., for presurgical localization), each 24 hours

95812 – 95822, 95827 Electroencephalogram (EEG)

Point to note: In response to a question on the use of EEG CPT codes 95812 and 95813, the American Academy of Neurology Routine clarified that length of monitoring is now defined as lasting 20 to 40 minutes. The extended monitoring codes are to be used for monitoring times greater than 40 minutes. Code 95812 is defined as covering 41-60 min of monitoring and code 95813 is defined as covering any monitoring that is greater than one hour. Codes 95812 and 95813 can be used in place of 95816, 95819 or 95822 but are not to be billed together with them.

95950 Monitoring for identification and lateralization of cerebral seizure focus, electroencephalographic (eg, 8 channel EEG) recording and interpretation, each 24 hours
95953 Monitoring for localization of cerebral seizure focus by computerized portable 16 or more channel EEG, electroencephalographic (EEG) recording and interpretation, each 24 hours unattended
95956 Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, electroencephalographic (EEG) recording and interpretation, each 24 hours, attended by a technologist or nurse
99184 Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling

Aetna also covers Deep brain stimulation CPT codes if selection criteria are met.

The National Association of Epilepsy Centers (NAEC) reported that in July, the AMA published a summary of the May 2018 CPT Editorial Panel Meeting. This includes approved changes to the Long Term EEG Monitoring Codes. These changes will not take effect until January 1, 2020, and physicians should continue to use the existing CPT codes for Long Term EEG Monitoring until that date. The coding changes approved by the Panel and released by the AMA are as follows:

• Deletion of CPT Codes 95827, 95950, 95951, 95953, and 95956
• Addition of 13 codes for the technical component of long term EEG services (95X01 – 95X13)
• The addition of 10 codes for the professional component of long term EEG services 95X14 – 95X23)
• Revisions to the EEG guidelines with definitions and parentheticals following codes 61533, 95812, 95813, 95816, 95819, 95822, 95827, 95967 will be included in the CPT Manual

An in-depth understanding of current guidelines or practices for billing and coding is necessary to submit claims for accurate reimbursement. Experienced medical billing and coding companies have that knowledge. Since a diagnosis of epilepsy can have serious legal and personal consequences for the patient, such as the inability to obtain a driver’s license, reliable medical coding service providers will assign a code for epilepsy based only on the condition that the physician identified as such in the diagnostic statement. They are also knowledgeable about the reimbursement policies of different payers and will verify patient’s insurance coverage before they arrive for treatment to ensure accurate claim submission.