Use 1 Code for 4-Limb EP Study
Question: A 34-year-old reports months of numbness and tingling in both hands and feet, now with unsteadiness when walking. The neurologist documents distal sensory loss and an unsteady gait, suspects a demyelinating process, and performs a short-latency somatosensory evoked potential (EP) study of both upper and lower limbs. The neurologist then interprets the latencies and amplitudes in a signed report. I was thinking about reporting 95925 and 95926. How many CPT® codes should I report for this encounter? Illinois Subscriber Answer: Because all four limbs were studied, the encounter resolves to a single code: 95938 (Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs). You should not report 95925 (… in upper limbs) and 95926 (… in lower limbs) since there is a combination code that covers both of these services. If the neurologist performed the EP with their own equipment, you can report 95938 alone. If the neurologist furnishes only the interpretation using a facility’s equipment, append modifier 26 (Professional component) to 95938. The neurologist’s documented signs during the workup support medical necessity: R20.2 (Paresthesia of skin) and R26.81 (Unsteadiness on feet). If the neurologist arrives at a definitive diagnosis later, swap the symptom codes for the confirmed ICD-10-CM diagnosis code. If they don’t reach a definitive diagnosis, report the documented signs and symptoms. Jennifer McNamara, CPC, CVBA, CRC, CPMA, CDEO,
CEMA, COSC, CGSC, COPC, CPC-I, Contributing Writer
