Procedure: This 10-year-old female is referred for a 16-channel electroencephalogram due to unexplained seizures. During wakefulness, the posterior background is comprised predominately of 9 Hertz alpha activity, which is well modulated, symmetric, and responsive to eye opening. The anterior background contains 15-20 Hertz low voltage beta activity. With drowsiness there is attenuation of the posterior alpha rhythms, and 5-7 Hertz bi-temporal and sensual beta rhythms are noted. With early stage 2 sleep, there is 3-4 Hertz slowing of the record with occasional midline vertex waves and synchronous sleep spindle formation. No lateralizing asymmetries or epileptiform discharges are noted. Total duration was 4 hours.
Impression: This is an unremarkable awake, drowsy, and stage 2 sleep electroencephalogram. No evidence of ictal discharges or lateralizing asymmetries.
Select the appropriate CPT and ICD-10-CM codes.

Question

Quizplus · Accepted Answer

The CPT code 95819 is for a routine EEG with 16 or more channels, and ICD-10-CM code R56.9 is for unspecified convulsions, which aligns with the unexplained seizures described.

Procedure: This 10-Year-Old Female Is Referred for a 16-Channel Electroencephalogram