CPT Code: 95930  Region: 26

Covered states:  Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, Texas

Title:  Visual Evoked Potential

Category
Electrodiagnostic Services

Description
Visual evoked potential testing



Visual evoked potential studies are recorded electrical responses to stimulation of a sensory system.  When a sensory impulse reaches the brain, a specific electroencephalographic (EEG) response is produced (evoked) in the cortical area appropriate to the modality and site of the stimulus.  By computer averaging techniques, the evoked responses of repetitive stimuli can be separated from the spontaneous EEG activity.  Evoked potentials are clinically useful in evaluating the functional integrity of the somatosensory or special sensory pathways.  Different latencies and wave patterns help to localize lesions ranging from the end organ through the nervous system to the cerebral cortex.  Often defects in these pathways are not otherwise evident.  Evoked potentials are also used to monitor neural pathways when patients are anesthetized during surgery and to document brain death. 


VEPs/VERs
 evaluate the visual nervous system pathways from the eyes to the occipital cortex of the brain.  VEP or VER involves stimulation of the retina and optic nerve with a shifting checkerboard pattern or flash method.  This external visual stimulus causes measurable electrical activity in neurons within the visual pathways.  This is called the Visual Evoked Response (VER) and is recorded by electroencephalography electrodes located over the occiput.  Using special computer techniques, the evoked responses measured over multiple trials are amplified and averaged.  A characteristic waveform is produced.  With pattern-shift VER, the waveform normally appears as a straight line with a single positive peak (100 msec after stimulus presentation).  Abnormalities in this characteristic waveform may be seen in a variety of pathologic processes involving the optic nerve and its radiations.  Pattern-shift VER is a highly sensitive means of documenting lesions in the visual system.  It is especially useful when the disease process is subclinical, e.g., ophthalmologic exam is normal and patient lacks visual symptoms.

Visual evoked potentials are appropriate for the following indications:

1.  Confirm diagnosis of multiple sclerosis when clinical criteria are inconclusive.
2.  Detect optic neuritis at an early, subclinical stage.
3.  Evaluate diseases of the optic nerve, such as:

  • Ischemic optic neuropathy
  • Pseudotumor cerebri
  • Toxic amblyopias
  • Nutritional amblyopias
  • Neoplasms compressing the anterior visual pathways
  • Optic nerve injury or atrophy
  • Hysterical blindness (to rule out)

4.  Monitor the visual system during optic nerve (or related) surgery (monitoring of short-latency evoked potential studies).

As published in CMS IOM 100-08, Chapter 13, Section 13.5.1, in order to be covered under Medicare, a service shall be reasonable and necessary.  When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862 (a)(1)(A).  Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

  • Safe and effective
  • Not experimental or investigational (exception: routine codes of qualifying clinical trial services with dates of service on or after September 19, 2000, that meet the requirements of the Clinical Trials NCD are considered reasonable and necessary
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member
    • Furnished in a setting appropriate to the patient’s medical needs and condition
    • Ordered and furnished by qualified personnel
    • One that meets, but does not exceed, the patient’s medical needs
    • At least as beneficial as an existing and available medically appropriate alternative

**Covered diagnosis codes for Texas’ Managed Care Medicaid can be found in Appendix 1

ICD-10 Diagnosis Codes

ICD-10 CategoryICD-10 CodeDescription
Diseases of the eye and adnexa H35.54 Dystrophies primarily involving the retinal pigment epithelium
Diseases of the eye and adnexa H46.01 Optic papillitis, right eye
Diseases of the eye and adnexa H46.02 Optic papillitis, left eye
Diseases of the eye and adnexa H46.03 Optic papillitis, bilateral
Diseases of the eye and adnexa H46.11 Retrobulbar neuritis, right eye
Diseases of the eye and adnexa H46.12 Retrobulbar neuritis, left eye
Diseases of the eye and adnexa H46.13 Retrobulbar neuritis, bilateral
Diseases of the eye and adnexa H46.2 Nutritional optic neuropathy
Diseases of the eye and adnexa H46.3 Toxic optic neuropathy
Diseases of the eye and adnexa H46.8 Other optic neuritis
Diseases of the eye and adnexa H47.011 Ischemic optic neuropathy, right eye
Diseases of the eye and adnexa H47.012 Ischemic optic neuropathy, left eye
Diseases of the eye and adnexa H47.013 Ischemic optic neuropathy, bilateral
Diseases of the eye and adnexa H47.021 Hemorrhage in optic nerve sheath, right eye
Diseases of the eye and adnexa H47.022 Hemorrhage in optic nerve sheath, left eye
Diseases of the eye and adnexa H47.023 Hemorrhage in optic nerve sheath, bilateral
Diseases of the eye and adnexa H47.031 Optic nerve hypoplasia, right eye
Diseases of the eye and adnexa H47.032 Optic nerve hypoplasia, left eye
Diseases of the eye and adnexa H47.033 Optic nerve hypoplasia, bilateral
Diseases of the eye and adnexa H47.091 Other disorders of optic nerve, not elsewhere classified, right eye
Diseases of the eye and adnexa H47.092 Other disorders of optic nerve, not elsewhere classified, left eye
Diseases of the eye and adnexa H47.093 Other disorders of optic nerve, not elsewhere classified, bilateral
Diseases of the eye and adnexa H47.10 Unspecified papilledema
Diseases of the eye and adnexa H47.11 Papilledema associated with increased intracranial pressure
Diseases of the eye and adnexa H47.12 Papilledema associated with decreased ocular pressure
Diseases of the eye and adnexa H47.13 Papilledema associated with retinal disorder
Diseases of the eye and adnexa H47.141 Foster-Kennedy syndrome, right eye
Diseases of the eye and adnexa H47.142 Foster-Kennedy syndrome, left eye
Diseases of the eye and adnexa H47.143 Foster-Kennedy syndrome, bilateral
Diseases of the eye and adnexa H47.20 Unspecified optic atrophy
Diseases of the eye and adnexa H47.211 Primary optic atrophy, right eye
Diseases of the eye and adnexa H47.212 Primary optic atrophy, left eye
Diseases of the eye and adnexa H47.213 Primary optic atrophy, bilateral
Diseases of the eye and adnexa H47.231 Glaucomatous optic atrophy, right eye
Diseases of the eye and adnexa H47.232 Glaucomatous optic atrophy, left eye
Diseases of the eye and adnexa H47.233 Glaucomatous optic atrophy, bilateral
Diseases of the eye and adnexa H47.291 Other optic atrophy, right eye
Diseases of the eye and adnexa H47.292 Other optic atrophy, left eye
Diseases of the eye and adnexa H47.293 Other optic atrophy, bilateral
Diseases of the eye and adnexa H47.311 Coloboma of optic disc, right eye
Diseases of the eye and adnexa H47.312 Coloboma of optic disc, left eye
Diseases of the eye and adnexa H47.313 Coloboma of optic disc, bilateral
Diseases of the eye and adnexa H47.321 Drusen of optic disc, right eye
Diseases of the eye and adnexa H47.322 Drusen of optic disc, left eye
Diseases of the eye and adnexa H47.323 Drusen of optic disc, bilateral
Diseases of the eye and adnexa H47.331 Pseudopapilledema of optic disc, right eye
Diseases of the eye and adnexa H47.332 Pseudopapilledema of optic disc, left eye
Diseases of the eye and adnexa H47.333 Pseudopapilledema of optic disc, bilateral
Diseases of the eye and adnexa H47.391 Other disorders of optic disc, right eye
Diseases of the eye and adnexa H47.392 Other disorders of optic disc, left eye
Diseases of the eye and adnexa H47.393 Other disorders of optic disc, bilateral
Diseases of the eye and adnexa H47.41 Disorders of optic chiasm in (due to) inflammatory disorders
Diseases of the eye and adnexa H47.42 Disorders of optic chiasm in (due to) neoplasm
Diseases of the eye and adnexa H47.43 Disorders of optic chiasm in (due to) vascular disorders
Diseases of the eye and adnexa H47.49 Disorders of optic chiasm in (due to) other disorders
Diseases of the eye and adnexa H47.511 Disorders of visual pathways in (due to) inflammatory disorders, right side
Diseases of the eye and adnexa H47.512 Disorders of visual pathways in (due to) inflammatory disorders, left side
Diseases of the eye and adnexa H47.521 Disorders of visual pathways in (due to) neoplasm, right side
Diseases of the eye and adnexa H47.522 Disorders of visual pathways in (due to) neoplasm, left side
Diseases of the eye and adnexa H47.531 Disorders of visual pathways in (due to) vascular disorders, right side
Diseases of the eye and adnexa H47.532 Disorders of visual pathways in (due to) vascular disorders, left side
Diseases of the eye and adnexa H47.611 Cortical blindness, right side of brain
Diseases of the eye and adnexa H47.612 Cortical blindness, left side of brain
Diseases of the eye and adnexa H47.621 Disorders of visual cortex in (due to) inflammatory disorders, right side of brain
Diseases of the eye and adnexa H47.622 Disorders of visual cortex in (due to) inflammatory disorders, left side of brain
Diseases of the eye and adnexa H47.631 Disorders of visual cortex in (due to) neoplasm, right side of brain
Diseases of the eye and adnexa H47.632 Disorders of visual cortex in (due to) neoplasm, left side of brain
Diseases of the eye and adnexa H47.641 Disorders of visual cortex in (due to) vascular disorders, right side of brain
Diseases of the eye and adnexa H47.642 Disorders of visual cortex in (due to) vascular disorders, left side of brain
Diseases of the eye and adnexa H53.001 Unspecified amblyopia, right eye
Diseases of the eye and adnexa H53.002 Unspecified amblyopia, left eye
Diseases of the eye and adnexa H53.003 Unspecified amblyopia, bilateral
Diseases of the eye and adnexa H53.011 Deprivation amblyopia, right eye
Diseases of the eye and adnexa H53.012 Deprivation amblyopia, left eye
Diseases of the eye and adnexa H53.013 Deprivation amblyopia, bilateral
Diseases of the eye and adnexa H53.021 Refractive amblyopia, right eye
Diseases of the eye and adnexa H53.022 Refractive amblyopia, left eye
Diseases of the eye and adnexa H53.023 Refractive amblyopia, bilateral
Diseases of the eye and adnexa H53.029 Refractive amblyopia, unspecified eye
Diseases of the eye and adnexa H53.031 Strabismic amblyopia, right eye
Diseases of the eye and adnexa H53.032 Strabismic amblyopia, left eye
Diseases of the eye and adnexa H53.033 Strabismic amblyopia, bilateral
Diseases of the eye and adnexa H53.10 Unspecified subjective visual disturbances
Diseases of the eye and adnexa H53.11 Day blindness
Diseases of the eye and adnexa H53.121 Transient visual loss, right eye
Diseases of the eye and adnexa H53.122 Transient visual loss, left eye
Diseases of the eye and adnexa H53.123 Transient visual loss, bilateral
Diseases of the eye and adnexa H53.131 Sudden visual loss, right eye
Diseases of the eye and adnexa H53.132 Sudden visual loss, left eye
Diseases of the eye and adnexa H53.133 Sudden visual loss, bilateral
Diseases of the eye and adnexa H53.141 Visual discomfort, right eye
Diseases of the eye and adnexa H53.142 Visual discomfort, left eye
Diseases of the eye and adnexa H53.143 Visual discomfort, bilateral
Diseases of the eye and adnexa H53.15 Visual distortions of shape and size
Diseases of the eye and adnexa H53.16 Psychophysical visual disturbances
Diseases of the eye and adnexa H53.19 Other subjective visual disturbances
Diseases of the eye and adnexa H53.2 Diplopia
Diseases of the eye and adnexa H53.30 Unspecified disorder of binocular vision
Diseases of the eye and adnexa H53.31 Abnormal retinal correspondence
Diseases of the eye and adnexa H53.32 Fusion with defective stereopsis
Diseases of the eye and adnexa H53.33 Simultaneous visual perception without fusion
Diseases of the eye and adnexa H53.34 Suppression of binocular vision
Diseases of the eye and adnexa H53.411 Scotoma involving central area, right eye
Diseases of the eye and adnexa H53.412 Scotoma involving central area, left eye
Diseases of the eye and adnexa H53.413 Scotoma involving central area, bilateral
Diseases of the eye and adnexa H53.421 Scotoma of blind spot area, right eye
Diseases of the eye and adnexa H53.422 Scotoma of blind spot area, left eye
Diseases of the eye and adnexa H53.423 Scotoma of blind spot area, bilateral
Diseases of the eye and adnexa H53.431 Sector or arcuate defects, right eye
Diseases of the eye and adnexa H53.432 Sector or arcuate defects, left eye
Diseases of the eye and adnexa H53.433 Sector or arcuate defects, bilateral
Diseases of the eye and adnexa H53.451 Other localized visual field defect, right eye
Diseases of the eye and adnexa H53.452 Other localized visual field defect, left eye
Diseases of the eye and adnexa H53.453 Other localized visual field defect, bilateral
Diseases of the eye and adnexa H53.461 Homonymous bilateral field defects, right side
Diseases of the eye and adnexa H53.462 Homonymous bilateral field defects, left side
Diseases of the eye and adnexa H53.47 Heteronymous bilateral field defects
Diseases of the eye and adnexa H53.481 Generalized contraction of visual field, right eye
Diseases of the eye and adnexa H53.482 Generalized contraction of visual field, left eye
Diseases of the eye and adnexa H53.483 Generalized contraction of visual field, bilateral
Diseases of the eye and adnexa H53.50 Unspecified color vision deficiencies
Diseases of the eye and adnexa H53.51 Achromatopsia
Diseases of the eye and adnexa H53.52 Acquired color vision deficiency
Diseases of the eye and adnexa H53.53 Deuteranomaly
Diseases of the eye and adnexa H53.54 Protanomaly
Diseases of the eye and adnexa H53.55 Tritanomaly
Diseases of the eye and adnexa H53.59 Other color vision deficiencies
Diseases of the eye and adnexa H53.60 Unspecified night blindness
Diseases of the eye and adnexa H53.61 Abnormal dark adaptation curve
Diseases of the eye and adnexa H53.62 Acquired night blindness
Diseases of the eye and adnexa H53.63 Congenital night blindness
Diseases of the eye and adnexa H53.69 Other night blindness
Diseases of the eye and adnexa H53.71 Glare sensitivity
Diseases of the eye and adnexa H53.72 Impaired contrast sensitivity
Diseases of the eye and adnexa H53.8 Other visual disturbances
Neoplasms C70.0 Malignant neoplasm of cerebral meninges
Neoplasms C70.1 Malignant neoplasm of spinal meninges
Neoplasms C72.0 Malignant neoplasm of spinal cord
Neoplasms C72.1 Malignant neoplasm of cauda equina
Neoplasms C72.21 Malignant neoplasm of right olfactory nerve
Neoplasms C72.22 Malignant neoplasm of left olfactory nerve
Neoplasms C72.31 Malignant neoplasm of right optic nerve
Neoplasms C72.32 Malignant neoplasm of left optic nerve
Neoplasms C72.41 Malignant neoplasm of right acoustic nerve
Neoplasms C72.42 Malignant neoplasm of left acoustic nerve
Neoplasms C72.59 Malignant neoplasm of other cranial nerves
Neoplasms C79.31 Secondary malignant neoplasm of brain
Neoplasms C79.32 Secondary malignant neoplasm of cerebral meninges
Neoplasms C79.49 Secondary malignant neoplasm of other parts of nervous system
Neoplasms D32.0 Benign neoplasm of cerebral meninges
Neoplasms D32.1 Benign neoplasm of spinal meninges
Neoplasms D33.0 Benign neoplasm of brain, supratentorial
Neoplasms D33.1 Benign neoplasm of brain, infratentorial
Neoplasms D33.3 Benign neoplasm of cranial nerves
Neoplasms D33.4 Benign neoplasm of spinal cord
Neoplasms D33.7 Benign neoplasm of other specified parts of central nervous system
Neoplasms D42.0 Neoplasm of uncertain behavior of cerebral meninges
Neoplasms D42.1 Neoplasm of uncertain behavior of spinal meninges
Neoplasms D43.0 Neoplasm of uncertain behavior of brain, supratentorial
Neoplasms D43.1 Neoplasm of uncertain behavior of brain, infratentorial
Neoplasms D43.4 Neoplasm of uncertain behavior of spinal cord
Neoplasms D44.3 Neoplasm of uncertain behavior of pituitary gland
Neoplasms D44.4 Neoplasm of uncertain behavior of craniopharyngeal duct
Neoplasms D44.5 Neoplasm of uncertain behavior of pineal gland
Diseases of the nervous system G23.0 Hallervorden-Spatz disease
Diseases of the nervous system G23.1 Progressive supranuclear ophthalmoplegia [Steele-Richardson-Olszewski]
Diseases of the nervous system G23.2 Striatonigral degeneration
Diseases of the nervous system G23.8 Other specified degenerative diseases of basal ganglia
Diseases of the nervous system G23.9 Degenerative disease of basal ganglia, unspecified
Diseases of the nervous system G35 Multiple sclerosis
Diseases of the nervous system G36.0 Neuromyelitis optica [Devic]
Diseases of the nervous system G36.1 Acute and subacute hemorrhagic leukoencephalitis [Hurst]
Diseases of the nervous system G36.8 Other specified acute disseminated demyelination
Diseases of the nervous system G37.0 Diffuse sclerosis of central nervous system
Diseases of the nervous system G37.1 Central demyelination of corpus callosum
Diseases of the nervous system G37.2 Central pontine myelinolysis
Diseases of the nervous system G37.3 Acute transverse myelitis in demyelinating disease of central nervous system
Diseases of the nervous system G37.4 Subacute necrotizing myelitis of central nervous system
Diseases of the nervous system G37.5 Concentric sclerosis [Balo] of central nervous system
Diseases of the nervous system G37.8 Other specified demyelinating diseases of central nervous system
Diseases of the nervous system G90.3 Multi-system degeneration of the autonomic nervous system
Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified R44.1 Visual hallucinations
Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified R48.3 Visual agnosia
Injury, poisoning and certain other consequences of external causes S01.90XA Unspecified open wound of unspecified part of head, initial encounter
Injury, poisoning and certain other consequences of external causes S04.011A Injury of optic nerve, right eye, initial encounter
Injury, poisoning and certain other consequences of external causes S04.012A Injury of optic nerve, left eye, initial encounter
Injury, poisoning and certain other consequences of external causes S04.019A Injury of optic nerve, unspecified eye, initial encounter
Injury, poisoning and certain other consequences of external causes S04.02XA Injury of optic chiasm, initial encounter
Injury, poisoning and certain other consequences of external causes S04.031A Injury of optic tract and pathways, right eye, initial encounter
Injury, poisoning and certain other consequences of external causes S04.032A Injury of optic tract and pathways, left eye, initial encounter
Injury, poisoning and certain other consequences of external causes S04.039A Injury of optic tract and pathways, unspecified eye, initial encounter
Injury, poisoning and certain other consequences of external causes S04.041A Injury of visual cortex, right eye, initial encounter
Injury, poisoning and certain other consequences of external causes S04.042A Injury of visual cortex, left eye, initial encounter
Injury, poisoning and certain other consequences of external causes S04.049A Injury of visual cortex, unspecified eye, initial encounter
Injury, poisoning and certain other consequences of external causes S06.0X6A Concussion with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
Injury, poisoning and certain other consequences of external causes S06.0X7A Concussion with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.0X8A Concussion with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.0X9A Concussion with loss of consciousness of unspecified duration, initial encounter
Injury, poisoning and certain other consequences of external causes S06.310A Contusion and laceration of right cerebrum without loss of consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.311A Contusion and laceration of right cerebrum with loss of consciousness of 30 minutes or less, initial encounter
Injury, poisoning and certain other consequences of external causes S06.312A Contusion and laceration of right cerebrum with loss of consciousness of 31 minutes to 59 minutes, initial encounter
Injury, poisoning and certain other consequences of external causes S06.313A Contusion and laceration of right cerebrum with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter
Injury, poisoning and certain other consequences of external causes S06.314A Contusion and laceration of right cerebrum with loss of consciousness of 6 hours to 24 hours, initial encounter
Injury, poisoning and certain other consequences of external causes S06.315A Contusion and laceration of right cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
Injury, poisoning and certain other consequences of external causes S06.316A Contusion and laceration of right cerebrum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
Injury, poisoning and certain other consequences of external causes S06.317A Contusion and laceration of right cerebrum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.318A Contusion and laceration of right cerebrum with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.319A Contusion and laceration of right cerebrum with loss of consciousness of unspecified duration, initial encounter
Injury, poisoning and certain other consequences of external causes S06.320A Contusion and laceration of left cerebrum without loss of consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.321A Contusion and laceration of left cerebrum with loss of consciousness of 30 minutes or less, initial encounter
Injury, poisoning and certain other consequences of external causes S06.322A Contusion and laceration of left cerebrum with loss of consciousness of 31 minutes to 59 minutes, initial encounter
Injury, poisoning and certain other consequences of external causes S06.323A Contusion and laceration of left cerebrum with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter
Injury, poisoning and certain other consequences of external causes S06.324A Contusion and laceration of left cerebrum with loss of consciousness of 6 hours to 24 hours, initial encounter
Injury, poisoning and certain other consequences of external causes S06.325A Contusion and laceration of left cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
Injury, poisoning and certain other consequences of external causes S06.326A Contusion and laceration of left cerebrum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
Injury, poisoning and certain other consequences of external causes S06.327A Contusion and laceration of left cerebrum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.328A Contusion and laceration of left cerebrum with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.329A Contusion and laceration of left cerebrum with loss of consciousness of unspecified duration, initial encounter
Injury, poisoning and certain other consequences of external causes S06.330A Contusion and laceration of cerebrum, unspecified, without loss of consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.331A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, initial encounter
Injury, poisoning and certain other consequences of external causes S06.332A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 minutes, initial encounter
Injury, poisoning and certain other consequences of external causes S06.333A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter
Injury, poisoning and certain other consequences of external causes S06.334A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, initial encounter
Injury, poisoning and certain other consequences of external causes S06.335A Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
Injury, poisoning and certain other consequences of external causes S06.336A Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
Injury, poisoning and certain other consequences of external causes S06.337A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.338A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.339A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of unspecified duration, initial encounter
Injury, poisoning and certain other consequences of external causes S06.340A Traumatic hemorrhage of right cerebrum without loss of consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.341A Traumatic hemorrhage of right cerebrum with loss of consciousness of 30 minutes or less, initial encounter
Injury, poisoning and certain other consequences of external causes S06.342A Traumatic hemorrhage of right cerebrum with loss of consciousness of 31 minutes to 59 minutes, initial encounter
Injury, poisoning and certain other consequences of external causes S06.343A Traumatic hemorrhage of right cerebrum with loss of consciousness of 1 hours to 5 hours 59 minutes, initial encounter
Injury, poisoning and certain other consequences of external causes S06.344A Traumatic hemorrhage of right cerebrum with loss of consciousness of 6 hours to 24 hours, initial encounter
Injury, poisoning and certain other consequences of external causes S06.345A Traumatic hemorrhage of right cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
Injury, poisoning and certain other consequences of external causes S06.346A Traumatic hemorrhage of right cerebrum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
Injury, poisoning and certain other consequences of external causes S06.347A Traumatic hemorrhage of right cerebrum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.348A Traumatic hemorrhage of right cerebrum with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.349A Traumatic hemorrhage of right cerebrum with loss of consciousness of unspecified duration, initial encounter
Injury, poisoning and certain other consequences of external causes S06.350A Traumatic hemorrhage of left cerebrum without loss of consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.351A Traumatic hemorrhage of left cerebrum with loss of consciousness of 30 minutes or less, initial encounter
Injury, poisoning and certain other consequences of external causes S06.352A Traumatic hemorrhage of left cerebrum with loss of consciousness of 31 minutes to 59 minutes, initial encounter
Injury, poisoning and certain other consequences of external causes S06.353A Traumatic hemorrhage of left cerebrum with loss of consciousness of 1 hours to 5 hours 59 minutes, initial encounter
Injury, poisoning and certain other consequences of external causes S06.354A Traumatic hemorrhage of left cerebrum with loss of consciousness of 6 hours to 24 hours, initial encounter
Injury, poisoning and certain other consequences of external causes S06.355A Traumatic hemorrhage of left cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
Injury, poisoning and certain other consequences of external causes S06.356A Traumatic hemorrhage of left cerebrum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
Injury, poisoning and certain other consequences of external causes S06.357A Traumatic hemorrhage of left cerebrum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.358A Traumatic hemorrhage of left cerebrum with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.359A Traumatic hemorrhage of left cerebrum with loss of consciousness of unspecified duration, initial encounter
Injury, poisoning and certain other consequences of external causes S06.360A Traumatic hemorrhage of cerebrum, unspecified, without loss of consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.361A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, initial encounter
Injury, poisoning and certain other consequences of external causes S06.362A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 minutes, initial encounter
Injury, poisoning and certain other consequences of external causes S06.363A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 1 hours to 5 hours 59 minutes, initial encounter
Injury, poisoning and certain other consequences of external causes S06.364A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, initial encounter
Injury, poisoning and certain other consequences of external causes S06.365A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
Injury, poisoning and certain other consequences of external causes S06.366A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
Injury, poisoning and certain other consequences of external causes S06.367A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.368A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.369A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of unspecified duration, initial encounter
Injury, poisoning and certain other consequences of external causes S06.370A Contusion, laceration, and hemorrhage of cerebellum without loss of consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.371A Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 30 minutes or less, initial encounter
Injury, poisoning and certain other consequences of external causes S06.372A Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 31 minutes to 59 minutes, initial encounter
Injury, poisoning and certain other consequences of external causes S06.373A Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter
Injury, poisoning and certain other consequences of external causes S06.374A Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 6 hours to 24 hours, initial encounter
Injury, poisoning and certain other consequences of external causes S06.375A Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
Injury, poisoning and certain other consequences of external causes S06.376A Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
Injury, poisoning and certain other consequences of external causes S06.377A Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.378A Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.379A Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of unspecified duration, initial encounter
Injury, poisoning and certain other consequences of external causes S06.380A Contusion, laceration, and hemorrhage of brainstem without loss of consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.381A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 30 minutes or less, initial encounter
Injury, poisoning and certain other consequences of external causes S06.382A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 31 minutes to 59 minutes, initial encounter
Injury, poisoning and certain other consequences of external causes S06.383A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter
Injury, poisoning and certain other consequences of external causes S06.384A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 6 hours to 24 hours, initial encounter
Injury, poisoning and certain other consequences of external causes S06.385A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
Injury, poisoning and certain other consequences of external causes S06.386A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
Injury, poisoning and certain other consequences of external causes S06.387A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.388A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.389A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of unspecified duration, initial encounter
Injury, poisoning and certain other consequences of external causes S06.4X0A Epidural hemorrhage without loss of consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.4X1A Epidural hemorrhage with loss of consciousness of 30 minutes or less, initial encounter
Injury, poisoning and certain other consequences of external causes S06.4X2A Epidural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, initial encounter
Injury, poisoning and certain other consequences of external causes S06.4X3A Epidural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter
Injury, poisoning and certain other consequences of external causes S06.4X4A Epidural hemorrhage with loss of consciousness of 6 hours to 24 hours, initial encounter
Injury, poisoning and certain other consequences of external causes S06.4X5A Epidural hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
Injury, poisoning and certain other consequences of external causes S06.4X6A Epidural hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
Injury, poisoning and certain other consequences of external causes S06.4X7A Epidural hemorrhage with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.4X8A Epidural hemorrhage with loss of consciousness of any duration with death due to other causes prior to regaining consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.4X9A Epidural hemorrhage with loss of consciousness of unspecified duration, initial encounter
Injury, poisoning and certain other consequences of external causes S06.5X0A Traumatic subdural hemorrhage without loss of consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.5X1A Traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, initial encounter
Injury, poisoning and certain other consequences of external causes S06.5X2A Traumatic subdural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, initial encounter
Injury, poisoning and certain other consequences of external causes S06.5X3A Traumatic subdural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter
Injury, poisoning and certain other consequences of external causes S06.5X4A Traumatic subdural hemorrhage with loss of consciousness of 6 hours to 24 hours, initial encounter
Injury, poisoning and certain other consequences of external causes S06.5X5A Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
Injury, poisoning and certain other consequences of external causes S06.5X6A Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
Injury, poisoning and certain other consequences of external causes S06.5X7A Traumatic subdural hemorrhage with loss of consciousness of any duration with death due to brain injury before regaining consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.5X8A Traumatic subdural hemorrhage with loss of consciousness of any duration with death due to other cause before regaining consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.5X9A Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter
Injury, poisoning and certain other consequences of external causes S06.6X0A Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.6X1A Traumatic subarachnoid hemorrhage with loss of consciousness of 30 minutes or less, initial encounter
Injury, poisoning and certain other consequences of external causes S06.6X2A Traumatic subarachnoid hemorrhage with loss of consciousness of 31 minutes to 59 minutes, initial encounter
Injury, poisoning and certain other consequences of external causes S06.6X3A Traumatic subarachnoid hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter
Injury, poisoning and certain other consequences of external causes S06.6X4A Traumatic subarachnoid hemorrhage with loss of consciousness of 6 hours to 24 hours, initial encounter
Injury, poisoning and certain other consequences of external causes S06.6X5A Traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
Injury, poisoning and certain other consequences of external causes S06.6X6A Traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
Injury, poisoning and certain other consequences of external causes S06.6X7A Traumatic subarachnoid hemorrhage with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.6X8A Traumatic subarachnoid hemorrhage with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter
Injury, poisoning and certain other consequences of external causes S06.6X9A Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, initial encounter


1.   All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.

2.  Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)).  The documentation must include the legible signature of the optometrist or ophthalmologist responsible for and providing the care to the patient.

3.  The submitted medical record must support the use of the selected ICD-10-CM code(s).  The submitted CPT/HCPCS code must describe the service performed.

4.  The medical record documentation must support the medical necessity of the services as directed in this policy.

5.  The patient’s medical record must contain documentation that fully supports the medical necessity for NEPs as covered by Medicare.  This documentation includes, but is not limited to, relevant medical history, physical examination and results of pertinent diagnostic tests or procedures.

1.  Report a VEP with CPT code 95930.  This is a bilateral test, therefore no modifiers are required if both eyes are examined.  A unit of “1” is placed in the unit field of the CMS 1500 form or its electronic equivalent.

2.  A VEP test is usually reported globally, but it may be separated into a professional component (modifier -26 and a technical component (modifier -TC) if necessary.

3.  VEP test can be done with general or direct supervision by the optometrist/ophthalmologist depending on if the technician is certified or non-technicians are now able to become certified by the American Board of Physical Therapy Specialties (ABPTS) to perform sensitive and complex neurophysiological studies.  If your technician is certified, a VEP test may be performed under general supervision (the doctor is not immediately available).  If your technician is not ABPTS certified, a VEP test must be performed with direct supervision (doctor is immediately available).

4.  An eye examination may be reported on the same day as a visual evoked potential test if it is medically necessary.

In general, VEP testing is reimbursed when it is reasonable and medically necessary.  Since there are no published utilization guidelines for VEP testing, doctors should adhere to CMS Ruling 95-1 (V) which states that utilization of VEP testing should be consistent with locally acceptable standards of practice.

According to the International Society for Clinical Electrophysiology of Vision, a minimum of two VEP recordings should be acquired, measured, and displayed to confirm the reproducibility of data if the findings are abnormal.  Also, it is usually not medically necessary to perform more than two VEP tests in a twelve-month period to diagnose and treat optic nerve disease.

Amerigroup – Clinical Guideline


Description

Visual evoked potentials (VEPs)This document addresses non-operative uses of the following evoked potential (EP) studies:

Evoked potentials (EPs) or evoked responses are electrical waves created in the central nervous system by peripheral stimulation of a sensory organ. EPs are used to identify abnormal central nervous system function that may not be detected clinically.


Clinical Indications

Multiple sclerosis or neuromyelitis optica (NMO), or other demyelinating disorders of the optic nerve;orVisual evoked potentials (VEPs) are considered medically necessary for the diagnosis, evaluation, or monitoring of any of the following conditions:

  • Suspected disorder of the optic nerve, optic chiasm or optic radiations not explained by MRI, CT, infectious diseases or metabolic disorders.

Visual evoked potentials (VEPs) are considered not medically necessary for all other uses, including but not limited to routine screening of infants.


Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.


ICD-10 Diagnosis Codes

ICD-10 CodesFor dates of service on or after 10/01/2015
F44.4 Conversion disorder with motor symptom or deficit [hysterical paralysis]
F68.10-F68.13 Factitious disorder
G11.1-G11.9 Hereditary ataxia
G23.0-G23.9 Other degenerative diseases of basal ganglia
G35 Multiple sclerosis
G36.0-36.9 Other acute disseminated demyelination
G37.0-G37.9 Other demyelinating disease of central nervous system
G93.1 Anoxic brain damage, not elsewhere classified
G93.82 Brain death
G95.9 Disease of spinal cord, unspecified (myelopathy NOS)
G97.81-G97.82 Other intraoperative and postprocedural complications and disorders of nervous system
H46.00-H46.9 Optic neuritis
H47.011-H47.49 Disorders of optic nerve, not elsewhere classified
H54.0-H54.8 Blindness and low vision
P84 Other problems with newborn (asphyxia of newborn NOS)
P91.60-P91.63 Hypoxic ischemic encephalopathy [HIE]
R40.20-R40.244 Coma
S06.1X6A-S06.9X6S Intracranial injury (with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving [code range with 6th character 6 and 7th character A-S]
S14.111A-S14.119S Complete lesion of cervical spinal cord
S14.141A-S14.149S Brown-Sequard syndrome of cervical spinal cord
S14.151A-S14.159S Other incomplete lesions of cervical spinal cord
S24.111A-S24.119S Complete lesion of thoracic spinal cord
S24.141A-S24.149S Brown-Sequard syndrome of thoracic spinal cord
S24.151A-S24.159S Other incomplete lesions of thoracic spinal cord
S34.111A-S34.119S Complete lesion of lumbar spinal cord
S34.121A-S34.129S Incomplete lesion of lumbar spinal cord
S34.131A-S34.139S Other and unspecified injury to sacral spinal cord
S34.3XXA-S34.3XXS Injury of cauda equina



ICD-9 Diagnosis Codes

ICD-9 CodeFor dates of service prior to 10/01/2015
300.10-300.19 Dissociative, conversion and factitious disorders [hysterical or factitious paralysis]
333 Other degenerative diseases of the basal ganglia
334.0-334.9 Spinocerebellar disease
336.9 Unspecified disease of spinal cord (myelopathy NOS)
340 Multiple sclerosis
341.0-341.9 Other demyelinating diseases of central nervous system
348.1 Anoxic brain damage
348.82 Brain death
369.00-369.9 Blindness and low vision
377.00-377.54 Disorders of the optic nerve
377.9 Unspecified disorder of optic nerve and visual pathways
768.5-768.6 Birth asphyxia
768.70-768.73 Hypoxic-ischemic encephalopathy [HIE]
768.9 Unspecified birth asphyxia in liveborn infant
780.01 Coma
854.00-854.19 Intracranial injury of other and unspecified nature
952.01 Spinal cord injury without evidence of spinal bone injury, C1-C4 level with complete lesion of spinal cord
952.04 Spinal cord injury without evidence of spinal bone injury, C1-C4 level with other specified spinal cord injury
952.06. Spinal cord injury without evidence of spinal bone injury, C5-C7 level with complete lesion of spinal cord
952.09 Spinal cord injury without evidence of spinal bone injury, C5-C7 level with other specified spinal cord injury
952.11 Spinal cord injury without evidence of spinal bone injury, T1-T6 level with complete lesion of spinal cord
952.14 Spinal cord injury without evidence of spinal bone injury, T1-T6 level with other specified spinal cord injury
951.16 Spinal cord injury without evidence of spinal bone injury, T7-T12 level with complete lesion of spinal cord
952.19. Spinal cord injury without evidence of spinal bone injury, T7-T12 level with other specified spinal cord injury
952.2 Spinal cord injury without evidence of spinal bone injury, lumbar
952.3 Spinal cord injury without evidence of spinal bone injury, sacral
952.4 Cauda equina
997.01 Central nervous system complication (anoxic brain damage)



Discussion
 

EPs are recordings of the nervous system’s electrical response to the stimulation of specific sensory pathways. These recordings have the ability to provide information relative to the functional integrity of pathways within the nervous system. Only a few EPs are used on a routine basis and those most frequently encountered include VEPs and SSEPs.

Visual Evoked Potentials (VEPs)

VEPs track signals from the retina to the visual cortex and determine how a visual system reacts to light. A common indication for VEPs is to help confirm the diagnosis of MS, or to evaluate and monitor MS. In general, myelin plaques which occur in MS slow the speed of VEP wave peaks. Over time VEPs in individuals with MS become progressively slower eventually attenuating in amplitude as demyelination increases (Creel, 2012). The American Academy of Neurology (AAN) (Gronseth, 2000) recommends VEPs as probably useful to identify those at increased risk for clinically definite MS.

VEPs have also been used for other conditions including neuromyelitis optica (NMO) or other demyelinating disorders of the optic nerves, or for a suspected disorder of the optic nerve, optic chiasm or optic radiations not explained by magnetic resonance imaging (MRI), computerized tomography (CT), infectious diseases or metabolic disorders.

The U.S. Preventive Services Task Force (USPSTF) (2011) has not recommended vision screening for infants and young children. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of vision screening for children less than 3 years of age.