CMS Issues Final Ruling on EEG CPT Coding Changes

CMS to Study Technical Codes in 2020; Contractor Pricing in Effect

On Friday, Nov. 1, CMS released its final rule as an unpublished 2020 Revisions to Payment Policies under the Physician Fee Schedule and Other Changes, which will be published on Nov. 15. The full report can be accessed here

Lifelines Neuro Chairman and Founder, Simon Griffin joined a coalition of neurodiagnostic industry leaders, including Centennial Neurodiagnostics, Neurovative, Ambulatory Neurological Services, and Corticare, in lobbying Congress to appeal to CMS for further evaluation.  Following is Griffin's analysis of the coding changes:

  • The new AMA CPT Code set for Long Duration EEG will be adopted on Jan. 1, 2020
  • There are no changes to the shorter duration EEG codes (less than two hours)
  • CMS has withdrawn the proposed national pricing for the technical codes in this new code set
  • CMS has chosen to have these codes contractor priced for 2020 
  • CMS has established national pricing for the Professional Codes
  • The valuations for Professional Codes have been increased by a very small amount over the originally proposed values, but are still significantly reduced compared to 2019

This is partially good news regarding the proposed changes to long-duration EEG coding. CMS, after listening to the concerns raised about access to patient care, has agreed to postpone coding changes for a year. 2020 will be used to gather more data and national pricing could be established in a future rule. Until then, the codes will be subjected to contractor pricing.

What does Contractor Pricing Mean?

Historically, the old code, 95951, has been contractor-priced.  CMS never set national pricing for this code. Providers in effect negotiate with the regional Medicare Contractors for billing and payment for services that are contractor-priced. 

This is not uncommon; the thinking is that an appropriate equilibrium is achieved where the provider and contractor are satisfied. This actually may be a bit of a challenge, since the codes being adopted in 2020 are new and are not directly analogous to the codes that they are replacing. There will likely be a transition period while the levels stabilize. However, this is considerably better than the very low levels of national reimbursement that were being proposed in the original CMS ruling.

Following is a breakdown of the ruling in simple terms, as the report is 2,475 pages, with the EEG codes starting on page 738 to 784 with charts on page 823. Here are some important highlights as I read the comments and the response to the comments by CMS:

Starting on Page 745 as it relates to the EEG setup code 95700:

“Provide education/obtain consent” (CA011) activity from 13 minutes to 7 minutes”

CMS puts a great deal of effort into understanding the work that is performed, evaluating to the minute how long they believe it should take to educate and obtain consent from a patient. This level of estimation is applied to all the steps.

“We also proposed to refine the quantity of the non-sterile gloves (SB022) supply from 3 to 2 for CPT code 95700.”

They also examined in detail exactly what supplies are used.  However, I don’t believe they really understand what is done, as you can see in the excerpt below, they still state that preparing and starting an IV is part of the EEG process!

“Due to the nature of the continuous recording EEG service taking place, we agree that the survey median clinical labor times of 12 minutes for the “Prepare room, equipment and supplies” (CA013) activity, 45 minutes for the “Prepare, set-up and start IV, initial positioning and monitoring of patient”(CA016) activity, and 22 minutes for the “Clean room/equipment by clinical staff” (CA024) activity would be typical for this procedure.”

Also, they clearly do not understand that disposable EEG electrodes are now really the standard of care and now recommended by all the academic societies and expected by regulatory agencies such as Joint Commission.

“We continue to believe that the use of disposable electrodes would not be typical for CPT code 95700, as the recommended materials specifically stated that reusable electrodes would instead be typical.”

The next comment about the patient to staff ratios is very important as it will set the standards by which payors will base their payments. Providers will have to be able to validate and support these ratios when audited.

“We continue to believe that 4 patients would typically be monitored at a time under continuous monitoring and that 12 patients would typically be monitored at a time during intermittent monitoring.”

Final statements relating to technical and professional codes sets

“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.”

“While many of the same concerns apply to the PC component of these services, we note that the professional component of these services are currently valued using recommendations originally furnished by the RUC. Consequently, we believe it is appropriate to maintain national payment rates for the professional component of these services.”

Expect to see statements coming in the near future from ACNS, AAN, NAEC, ASET, and other stakeholders. We will continue to analyze the changes and update the neurodiagnostic community to any new important information that comes out.

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