CHAPTER 11 REIMBURSEMENT ISSUES IN AMBULATORY EEG MARC R. NUWER, MD, PhD Health care public policy now uses coding to communicate clearly the nature of services and diagnoses. In these days of digital processing, big databases, and automated processes these formal coding systems aid in many ways. Insurance carriers use coding to check whether to pay for services, and then to pay promptly without human review. Research teams evaluate outcomes using the large databases with coded patient care information. Government and hospital policies are tuned to screen for proper services using coding. Altogether, systematic coding of services and diagnoses are here to stay. All these uses depend on physicians and institutional coders entering diagnoses and procedural coding correctly in the first place. DIAGNOSTIC CODING Diagnostic coding in the United States uses the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). The World Health Organization (WHO) adopted the ICD-10 in the early 1990s. More than 100 countries use it in some form. The U.S. Centers for Disease Control and Prevention’s National Center for Health Statistics converted to it in its Clinical Modification (CM) in 2014 (1). Epilepsy, defined by the International League Against Epilepsy (ILAE) as recurrent unprovoked seizures more than 24 hours apart or a first-time unprovoked seizure with a high likelihood of recurrence, is subdivided into several categories in ICD-10-CM. Tables 11.1 and 11.2 show many ICD-10-CM codes for epilepsy and seizures. This WHO system is not always consistent with or easily harmonized with the most recent definitions and classifications promulgated by the ILAE (2,3). Symptomatic refers to presence of an etiologic basis of a focal seizure onset. Otherwise, ICD-10-CM considers the epilepsy to be idiopathic. This is so even though modern genetics and neuroscience reveal specific known findings associated with certain such disorders. Absence epilepsy and juvenile myoclonic epilepsy are given their own unique diagnostic code family in this system, as are a few other specific disorders. TABLE 11.1 International Classification of Diseases, Tenth Revision, Clinical Modification Epilepsy and Seizure-Related Codes DISEASES OF THE NERVOUS SYSTEM G40 Epilepsy and recurrent seizures EXCLUDES: conversion disorder with seizures (F44.5), convulsions NOS (R56.9), hippocampal sclerosis (G93.81), mesial temporal sclerosis (G93.81), post traumatic seizures (R56.1), seizure (convulsive) NOS (R56.9), seizure of newborn (P90), temporal sclerosis (G93.81), Todd’s paralysis (G83.8) USE: x = 01 for “not intractable, with status epilepticus” x = 09 for “not intractable, without status epilepticus” x = 11 for “intractable, with status epilepticus” x = 19 for “intractable, without status epilepticus” USE: z = 1 for “not intractable, with status epilepticus” z = 2 for “not intractable, without status epilepticus” z = 3 for “intractable, with status epilepticus” z = 4 for “intractable, without status epilepticus” G40.0x Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset Examples: Benign childhood epilepsy with centrotemporal EEG spikes, childhood epilepsy with occipital EEG paroxysms Excludes: adult onset localization-related epilepsy (G40.1-, G40.2-) G40.1x Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures Examples: Attacks without alteration of consciousness, epilepsia partialis continua, simple partial seizures developing into secondarily generalized seizures G40.2x Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures Examples: Attacks with alteration of consciousness, often with automatisms; complex partial seizures developing into secondarily generalized seizures G40.3x Generalized idiopathic epilepsy and epileptic syndromes Code also MERRF syndrome, if applicable (E88.42) G40.Ax Absence epilepsy syndrome Examples: Childhood absence epilepsy, juvenile absence epilepsy, absence epileptic syndrome G40.Bx Juvenile myoclonic epilepsy G40.4x Other generalized epilepsy and epileptic syndromes Examples: Epilepsy with grand mal, myoclonic, atonic, clonic, or tonic seizures or myoclonic encephalopathy G40.5x Epileptic seizures related to external causes Examples: Seizures related to alcohol, drugs, hormonal changes, sleep deprivation, or stress Code also, if applicable, associated epilepsy and recurrent seizures (G40.-) Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5) G40.8 Other epilepsy and recurrent seizures Examples: Epilepsies and epileptic syndromes undetermined as to whether they are focal or generalized, Landau–Kleffner syndrome G40.80z Other epilepsy G40.81z Lennox–Gastaut syndrome G40.82z Epileptic spasms G40.89 Other seizures Excludes: post traumatic seizures (R56.1), recurrent seizures NOS (G40.909), seizure NOS (R56.9) G40.9x Epilepsy, unspecified Examples: Unspecified Epilepsy, Epileptic convulsions, Epileptic fits, Epileptic seizures, Recurrent seizures, Seizure disorder NOS This table summarizes the ICD-10-CM codes (1) that apply to many Epilepsy and Seizures diagnoses. To use the table, the sixth and seventh digital characters are added to the end of the first five characters given in the table. The characters to use for the sixth and seventh characters are specified by the variables x and z, as noted at the top to the table. For example, Localization-related (focal, partial) symptomatic epilepsy with partial complex seizures, intractable, without status epilepticus, would be coded as G40.219 by adding 19 (intractable, without status epilepticus) onto the end of the Epilepsy code family G40.2. The seventh digit for many codes refers to whether the patient suffers from status epilepticus related to this diagnosis. The sixth digit refers to whether the epilepsy or seizures are refractory, that is, intractable. The following terms are to be considered equivalent to intractable: pharmacologically resistant, treatment resistant, medically refractory, and poorly controlled. In practice, the term intractable refers to a patient who continues to suffer seizures or has suffered a seizure in the past year. The latter tactic avoids repeatedly changing a patient’s diagnosis when he or she is seen frequently and sometimes did or did not have seizures since the most recent previous visit. TABLE 11.2 International Classification of Diseases, Tenth Revision, Clinical Modification, Additional Seizure, and Related Codes MENTAL, BEHAVIORAL, AND NEURODEVELOPMENTAL DISORDERS F44 Dissociative and conversion disorders Includes: conversion hysteria, conversion reaction, hysteria, hysterical psychosis Excludes: malingering [conscious simulation] (Z76.5) F44.5 Conversion disorder with seizures or convulsions Dissociative convulsions SYMPTOMS, SIGNS, AND ABNORMAL CLINICAL AND LABORATORY FINDINGS, NOT ELSEWHERE CLASSIFIED R56 Convulsions, not elsewhere classified Excludes: dissociative convulsions and seizures (F44.5), epileptic convulsions and seizures (G40.-), newborn convulsions and seizures (P90) R56.0 Febrile convulsions R56.00 Simple febrile convulsions, Febrile convulsions, Febrile seizure R56.01 Complex febrile convulsions Atypical febrile seizure, Complex febrile seizure, Complicated febrile seizure Excludes: status epilepticus (G40.901-) R56.1 Posttraumatic seizures Excludes: post traumatic epilepsy (G40.-) R56.9 Unspecified convulsions Convulsion disorder, Fit NOS, Recurrent convulsions, Seizure(s) (convulsive) NOS CERTAIN CONDITIONS ORIGINATING IN THE PERINATAL PERIOD P90 Convulsions of newborn Excludes: benign myoclonic epilepsy in infancy (G40.3-), benign neonatal convulsions (familial) (G40.3-)
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