How to Avoid Common Denials for EEG’s

Routine and long-term EEGs are critical diagnostic tools for neurological conditions, but healthcare practices often face denials when submitting claims for these tests. To avoid these denials, it’s essential to understand the most common reasons and how to address them effectively.

1. Routine EEG Not Done Prior to Long-Term EEG

Many insurers require a routine EEG (95816 or 95819) before authorizing a long-term EEG. Skipping this step and proceeding directly to a more expensive long-term EEG without justification often leads to claim denials.

Solution: Always perform and document a routine EEG before escalating to long-term EEG monitoring, unless there is a clear medical reason for bypassing the routine test.

2. Lack of Proper Documentation Supporting Long-Term EEG

If a long-term EEG is ordered without adequate documentation explaining why the routine EEG was insufficient, insurance companies may deny the claim.

Solution: Provide detailed documentation that supports the need for long-term EEG testing, particularly when symptoms (such as seizure activity) persist and weren’t captured by the routine EEG.

3. Frequency Limits or Medical Necessity Guidelines

Payers have strict frequency limits for how often EEGs, especially long-term EEGs, can be performed. Exceeding these limits without solid medical justification is a common reason for denials.

Solution: Review payer guidelines for EEG frequency and ensure you document why repeated EEG testing is necessary within a specific time frame.

4. Failure to Meet Criteria for Sleep EEG (CPT 95819)

Some insurance companies require clear justification for performing both awake and asleep EEGs. Without this, claims for CPT code 95819 may be denied.

Solution: Make sure your documentation explains the need for monitoring both awake and sleep states, such as the suspicion of sleep-related seizure activity.

5. Pre-Authorization Not Secured

Many insurers require pre-authorization for more advanced or expensive tests like long-term EEGs. Performing these tests without securing approval can lead to denials.

Solution: Always verify and secure pre-authorization from the insurance company before performing any EEG, especially for long-term or complex studies.

6. Elective or Non-Emergent Use of EEGs

Insurance companies are likely to deny EEG claims if they determine that the test was not urgent or medically necessary.

Solution: Clearly document the medical necessity and urgency of the EEG in the patient’s records, particularly when diagnosing conditions like epilepsy or frequent seizures.

7. EEG Performed Too Early or Without Conservative Management

Some payers may deny EEG claims if conservative treatments, such as medications or initial observations, weren’t fully explored before conducting an EEG.

Solution: Include comprehensive documentation of previous treatments or evaluations to justify the necessity of the EEG.

Healthcare practices can significantly reduce claim denials by adhering to payer-specific guidelines, ensuring proper documentation, and securing pre-authorization when necessary. Understanding and following these common requirements will help you avoid delays and denials in your EEG billing process.

For more information on how to streamline your revenue cycle management and avoid costly denials, schedule a free consultation.