EEG CPT Codes Impacted by MAC Rates
Six Months after CMS Ruling, EEG CPT Rates Still in Flux
By Simon Griffin, Chairman & Founder, Lifelines Neuro
It’s been a wild and rocky ride since CMS released changes for Long-Term EEG CPT Codes. However, there is promising news as rates begin to stabilize.
In the Physicians’ Fee Schedule final rule for 2020 published in November 2019, CMS stated: “In the context of the concerns raised regarding the applicability of the new code set in various settings of care and by the services furnished to patients with varying needs, we are persuaded by commenters that we should maintain the stability inherent in contractor pricing despite consideration of RUC-recommended direct PE inputs for these TC services.”
Since January we have been waiting on the 12 regional Medicare Administrative Contractors (MACS) to publish their rates for 2020, to see if they intended to maintain “the stability” in reimbursement for these important diagnostic procedures. Some published quickly, others have not published rates at all. Some have produced valuations that are very much in-line with the former code set, others have not.
During this reimbursement uncertainty, we experienced the ongoing COVID-19 pandemic. Guidance from regulatory bodies and medical societies has clearly stated the need for telemedicine and diagnostic testing availability outside of medical facilities. It is too early to know the long-term impact, but there appears to be a consensus that we are entering a new period where telemedicine and remote technologies are going to become increasingly important, are here to stay, and have rapidly been adopted.
US MAC Coverage
Stable MAC Reimbursement
Novitas (TX, OK, LA, etc and PA, NJ, etc) and First Coast (FL) were quick to publish rates that recognized the significant cost in equipment, supplies, and time required to perform monitored EEG procedures. For example, the 95700 setup and takedown code is valued at $250, the Intermittent Monitored Long-term EEG and Video code 95715 is valued at $1000 for a 12-26 hour recording. When the CMS rate for professional interpretation and review is added the value of the total procedure is very analogous to the previously used global code 95951.
Similarly, if we look at an ambulatory EEG recorded without video and no monitoring, previously billed as 95953 and reimbursed at about $400 per day, the setup 95700 fee is $250, the daily technical fee for recording 95708 is $150 and the professional fees provide for a slightly increased reimbursement over a 24 hour period.
Early indications are that Noridian (CA, NV and almost everything west of the Rockies) are releasing similar levels of valuation for the codes.
Low rate or unpublished MACs
The remaining MACs have either not published rates for the technical codes, or have published rates with significantly reduced reimbursements. Some of them are in the process of revising these initial valuations based on feedback from providers.
WPS (MO, IA, KS, NE, IN, MI) has not published values at this time. CGS (KY, OH) published very low rates, such as $35.00 for the 95700 setup code. They received a significant amount of negative feedback, which is understandable since valuations like this do not cover the cost of performing an EEG. It is understood that they are revising their valuations and will publish updated values in the future.
Palmetto (TN, GA, NC, SC, etc.) and NGS (IL, WI, MN, NY, and New England) have released reduced reimbursement rates which were seemingly derived from the APC rates (see below), and are also said to be considering revisions to the valuations.
For more information, visit the website of your respective MAC and search for their 2020 Physicians' Fee schedule.
Hospital-Based EEG Reimbursement
If performing hospital-based EEG, then you are likely tracking CPT utilization, but being reimbursed via DRG for inpatients, or based on the APC system for outpatients. APCs (Ambulatory Payment Classifications) are the U.S. government's method of paying for facility outpatient services for the Medicare program. A part of the Federal Balanced Budget Act of 1997 made CMS create a new Medicare OPPS (Outpatient Prospective Payment System) for hospital outpatient services. IOPPS is analogous to the Medicare prospective payment system for hospital inpatients known as a Diagnosis-Related Group (DRG).
The APC codes reimburse the same for all the 12-24 hour technical recording codes except for the recordings that are continuously monitored. This means the technical reimbursement for a 24-hour ambulatory EEG (unmonitored, no video) is exactly the same as a video EEG that is intermittently monitored even though there is a significant increase in the cost of the equipment to perform the study as well as the time needed to monitor the procedure.
Geography and MAC oversight limit which reimbursement process and level of reimbursement you can expect from these procedures. In some areas, it may not be economically feasible to provide the services, in others, it is perfectly viable. This has the potential to significantly impact patient access to services depending on where they live.
There is another caveat - state Medicaid programs and private insurance companies typically use CMS valuations as a baseline from which to set their own rates. Six months into 2020, these rates are either not set, or are under review in many regions, which has led to issues with non-payment or significantly delayed payment for services that have been provided.
What can you do?
Lifelines Neuro is part of a coalition of EEG companies that is leading the way in advocating on your behalf and for the patients you serve. We are the only EEG manufacturer in this coalition, and we believe it is important that stability and predictability be brought to reimbursement so that patients have access to the services they need, and our clients can offer the services at a fair valuation. Our coalition is directly engaging with the MACs to highlight issues with reimbursement levels. We are maintaining contacts with patient advocacy groups so they can appreciate the potential issues for patient access. We are also engaging with the political leadership in states where patient access may be adversely affected. If you are interested in joining the coalition please contact me - together we are stronger
Individually you can do all these things. If you have a significant negative impact due to poor MAC valuation, raise your concerns with your payors. Write to congressional and senate leadership in your state to express your concerns.
Terminology is key to reimbursement
The new CPT codes are for Long-Term EEG, this is the terminology that should be used when describing the services that are performed. There are no longer specific codes for Ambulatory EEG (AEEG) or any of the other terms we use, such as Continuous EEG (cEEG).
The term Ambulatory EEG has caused confusion for payers in the past. Ambulatory EEG systems have been around since the 70s and for most of their lifespan consisted of a patient-worn data recorder that collected EEG over an extended period, often for several days. Video was not part of the solution and was not even mentioned in the old 95953 ambulatory EEG CPT code.
As the technology evolved and developed, video EEG telemetry systems became smaller and more mobile, and many physicians started to see the benefits of collecting video EEG in settings outside of the traditional inpatient long-term monitoring unit for certain patients. With connectivity solutions that are available today, it is now entirely feasible to monitor long-term EEG regardless of the location of the patient. This was one of the driving forces behind the CPT code definition changes that were introduced in 2020.
Ambulatory EEG in 2020 is a subset of these long-term codes and is defined as a patient-worn EEG collection device that is not monitored during the recording session. I believe that it is very important not to describe all non-hospital based long-term EEG recordings as ambulatory to avoid continued confusion with payers.