Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the neurology and neuromuscular procedures represented by codes 95955, 95885, 95908, and 95927 provided on December 14, 2020.

You asked the Plan to pay for codes 95955, 95885, 95908, and 95927. You say that the medical records support the billing of codes 95955, 95885, 95908, and 95927. The Plan denied your request. The Plan says that the medical records do not support the billing of codes 95955, 95885, 95908, and 95927.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95955 is Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery). The definition of code 95885 is Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure). The definition of code 95908 is Nerve conduction studies; 3-4 studies. The definition of code 95927 is Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head. 

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for codes 95955, 95885, 95908, and 95927. Our reviewer says that the medical records support the billing of codes 95955, 95885, 95908, and 95927. Our reviewer found the enrollee is with diagnoses of Spinal stenosis in the lumbar region without neurogenic claudication, and Radiculopathy, lumbar region. The enrollee underwent decompression surgery and posterior fusion at the L2 - S1 levels on 12/14/20. Intraoperative neurophysiology monitoring was performed. This included upper SSEP, lower SSEP, NCV, lower needle EMG, and EEG. Code 95955 is to be used for the measurement of EEG activity during noncranial surgery. The intraoperative neurophysiology monitoring included continuous EEG monitoring throughout the surgical procedure. 

Code 95885 is to be used for needle electromyography each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study, limited study. For EMG studies performed with an NCS on the same day, one should bill using CPT codes 95885 for a limited study. This is considered an "add-on" code and may not be billed independent of an NCS code. This is billed in units based on the number of extremities tested. One unit includes all muscles tested in a particular extremity, with or without the relevant paraspinal muscles. The procedure code is supported by the clinical documentation in the case file. Code 95908 is to be used for Nerve conduction studies; 3-4 studies. The clinical documentation in the case file supports the use of code 95908. The use of code 95927 (Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head) is supported by the clinical documentation in the case file.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 95955, 95885, 95908, and 95927 have been met. Therefore, we decided that the Plan has to pay for the neurology and neuromuscular procedures represented by codes 95955, 95885, 95908, and 95927 provided on December 14, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.