Date Printed: June 26, 2017: 01:20 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.


Original Effective Date: 11/28/00

Reviewed: 08/25/16

Revised: 01/01/17

Subject: Evoked Potentials, Intraoperative Neurophysiologic Monitoring, and Quantitative Electroencephalography (QEEG)


Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Updates    


Evoked Potentials

Evoked potentials (EP) are responses (electrical signals) produced by the nervous system in response to a stimulus. These computerized tests help diagnose nerve disorders, locate the site of nerve damage, and help evaluate the patient’s condition after treatment or during surgery. There are several types of evoked potential tests including:

Auditory-evoked potentials: Auditory-evoked potentials, also known as brainstem auditory-evoked potentials (BAEPs) or brainstem auditory-evoked responses (BAERs) are brain waves resulting from sound stimuli. BAEPs are commonly used to monitor auditory function during procedures such as resection of a cerebellopontine angle tumor and are generated in response to auditory clicks.

Somatosensory Evoked Potentials (SSEPs): SSEPs are electrical waves that are generated by the response of sensory neurons to stimulation. Peripheral nerves, such as the median, ulnar or tibial nerve, are typically stimulated, but in some situations the spinal cord may be stimulated directly. Recording is done either cortically or at the level of the spinal cord above the surgical procedure

Motor Evoked Potentials (MEPs): MEPs are recorded from muscles following direct or transcranial electrical stimulation of motor cortex or by pulsed magnetic stimulation provided by a coil placed over the head. Peripheral motor responses (muscle activity) are recorded by electrodes placed on the skin at prescribed points along the motor pathways.

Visual-evoked potentials: Visual-evoked potentials (VEPs), also known as visual-evoked responses (VERs), are brain waves resulting from light stimuli. VEPs are used to track visual signals from the retina to the occipital cortex and are typically performed for surgery on lesions near the optic chiasm. VEPs are difficult to interpret due to their sensitivity to anesthesia, temperature and blood pressure. With electrodes placed at occipital and parietal locations of the scalp, a checkerboard pattern is projected on a screen and rapidly reversed 100 times at a rate of once or twice per second. The procedure is performed on each eye. In severely myopic patients (corrected visual acuity is less than 20/200) the checkerboard pattern cannot be seen. Because the checkerboard pattern testing is sometimes difficult in children, a flash technique is used where light-emitting diodes or a strobe are placed into goggles and placed on the patient’s face. Visual neural impulses from either method are recorded as they travel from the eye to the occipital cortex.

Vestibular Evoked Myogenic Potentials (VEMPs: Vestibular evoked myogenic potential (VEMP) testing (i.e., click evoked neurogenic vestibular potentials) is a neurophysiological assessment technique used to determine the function of the inner ear, specifically the utricle and saccule. VEMP has been investigated in the diagnosis and management of Meniere’s disease, vestibular neuritis, otosclerosis, and central nervous system disorders such as multiple sclerosis.

Intraoperative Neurophysiologic Monitoring

Intraoperative neurophysiologic monitoring (IONM) describes a variety of procedures that have been used to monitor the integrity of neural pathways during high-risk neurosurgical, orthopedic, and vascular surgeries. The principal goal of IONM is the identification of nervous system impairment in the hope that prompt intervention will prevent permanent deficits. Correctable factors at surgery include circulatory disturbance, excess compression from retraction, bony structures, or hematomas, or mechanical stretching. The technology is continuously evolving with refinements in equipment and analytic techniques, including recording, with several patients monitored under the supervision of a physician who is outside the operating room.

The different methodologies of monitoring include somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs) and:

Electromyogram (EMG) Monitoring and Nerve Conduction Velocity Measurements: EMG monitoring and nerve conduction velocity measurements can be performed in the operating room and may be used to assess the status of the peripheral nerves (eg, to identify the extent of nerve damage before nerve grafting or during resection of tumors). In addition, these techniques may be used during procedures around the nerve roots and around peripheral nerves to assess the presence of excessive traction or other impairment. Surgery in the region of cranial nerves can be monitored by electrically stimulating the proximal (brain) end of the nerve and recording via EMG in the facial or neck muscles. Thus, monitoring is done in the direction opposite that of SSEPs, but the purpose is similar to verify that the neural pathway is intact.

Electroencephalogram (EEG) Monitoring: Spontaneous EEG monitoring can be recorded during surgery and can be subdivided:

- EEG monitoring may identify those patients who would benefit from the use of a vascular shunt during the procedure to restore adequate cerebral perfusion. Conversely, shunts, which have an associated risk of iatrogenic complications, may be avoided in those patients in whom the EEG is normal. Carotid endarterectomy may be done with the patient under local anesthesia so that monitoring of cortical function can be directly assessed.

- ECoG is the recording of the EEG directly from a surgically exposed cerebral cortex. ECoG is typically used to define the sensory cortex and map the critical limits of a surgical resection.

Quantitative Electroencephalography (QEEG)

A quantitative electroencephalogram (QEEG), also known as brain mapping, analyzes the electrical activity obtained at as many as 25 sites on the brain and compares the analysis with information from a database of normal and abnormal brain activity. The results of the analysis can be displayed in a graphical form called a brain map. QEEG can provide insight into brain function relevant to certain neurologic conditions.


Evoked Potentials

Somatosensory evoked potentials (SSEP) meet the definition of medical necessity when performed to assist in the diagnosis of certain neuropathologic states in order to provide information for treatment management for ANY of the following conditions (this is not an all-inclusive list):

• Cervical spondylosis with myelopathy

• Coma

• Friedreich’s ataxia

• Hereditary and idiopathic peripheral neuropathies

• Inflammatory and toxic neuropathies

• Multiple sclerosis

• Myoclonus

• Spinal cord trauma

• Spinal cord tumors

• Spinal stenosis and other conditions where there is spinal cord compression

• Syringomyelia.

Visual-evoked potentials meet the definition of medical necessity when performed for any of the following conditions:

• To confirm a diagnosis of multiple sclerosis, evidenced by clinical signs and symptoms (i.e., diplopia, nystagmus, optic neuritis, and occasional papillitis)

• To assess visual function in an infant or child under age one

• To rule out hysterical blindness and suspected malingering

• To evaluate blindness due to optic trauma.

NOTE: Visual-evoked potentials do not meet the definition of medical necessity when performed on severely myopic members (corrected visual acuity is less than 20/200).

Auditory-evoked potentials meet the definition of medical necessity when performed for the following conditions:

• Evaluation of hearing loss with disturbed balance, unsteadiness of gait, or other symptoms suggestive of auditory system lesion

• Evaluation of symptoms suggestive of Meniere’s Disease

• Intrinsic brainstem lesions (i.e., multiple sclerosis, brainstem infarctions when auditory pathways are involved, brainstem gliomas, or degenerative disorders of the nervous system)

• Confirmation of brain death when EEG is inconclusive

• Intraoperative evaluation of the 8th cranial nerve when an acoustic neuroma is being removed

• Evaluation of dizziness when other causes have been ruled out continuing dizziness after failed treatment for the cause (arrhythmias, ear infection, headache, hypotension)

• Evaluation of hearing loss in child or neonate since no verbal response is required

• Assessment of hysterical or factitious hearing loss

• Evaluation to differentiate sensory (cochlear) from neural (8th cranial nerve) hearing loss

• Evaluation of “true vertigo”, as revealed by complete history and physical, suggesting vestibular disease.

Motor-evoked potentials using transcranial electrical stimulation meet the definition of medical necessity for evaluation of suspected hysterical or factitious paralysis.

Somatosensory-evoked potentials (SSEP), visual-evoked potentials, auditory-evoked potentials, and/or motor-evoked potentials (using transcranial electrical stimulation) do not meet the definition of medical necessity for all other uses.

Vestibular evoked myogenic potential (VEMP) testing is considered experimental or investigational. There is a lack of clinical evidence published in the peer-reviewed literature demonstrating that VEMP testing alters patient management or provides added benefit to health outcomes.

Intraoperative Monitoring

Intraoperative monitoring, which includes somatosensory-evoked potentials (SSEP), motor-evoked potentials(MEP) using transcranial electrical stimulation, brainstem auditory-evoked potentials (BAEP), EMG of cranial nerves, EEG, and electrocorticography (ECoG), meets the definition of medical necessity during spinal, neurologic, cranial or vascular procedures when ALL of the following criteria are met:

• Monitoring is ordered by the operating surgeon;

• Monitoring is performed by a licensed physician trained in clinical neurophysiology or by a trained technologist who is working under the direct supervision of a physician trained in neurophysiology;

• Monitoring is not interpreted by the operating surgeon but a licensed physician trained in clinical neurophysiology who provides real time supervision and interventional recommendations while monitoring in the operating room or remotely; AND

• Monitoring period includes only intraoperative time (may be cumulative and does not have to be continuous).

Examples of conditions in which intraoperative monitoring may be utilized include (this is not an all-inclusive list):

• Anterior approach for cervical procedures such as carotid artery endarterectomy

• Correction of cerebral vascular aneurysms, intracranial or spinal arteriovenous malformations, or scoliosis

• High risk thyroid surgery such as malignancy or toxic goiter

• Multi-level cervical fusions with instrumentation

• Nontraumatic spinal cord lesions

• Removal of spinal cord tumors or tumors that affect the cranial nerves

• Spinal procedures that pose a potential risk of significant damage to an essential CNS structure

• Spinal cord trauma.

Intraoperative monitoring of visual-evoked potentials is considered experimental or investigational for all indications There is insufficient evidence to permit conclusions on clinical utility or net health outcomes.

Due to the lack of U.S. Food and Drug Administration (FDA) approval, intraoperative monitoring of motor-evoked potentials using transcranial magnetic stimulation is considered experimental or investigational for all indications.

Quantitative electroencephalography (QEEG)

Quantitative electroencephalography (QEEG) meets the definition of medical necessity when performed as an adjunct to traditional EEG for the following conditions:

• epilepsy, when ANY of the following are met:

- the long-term EEG is inconclusive and additional testing for possible epileptic spikes or seizures is needed;

- ambulatory recording is needed to facilitate subsequent visual EEG interpretation; or

- for topographic voltage and dipole analysis in presurgical candidates with intractable epilepsy.

• cerebral vascular disease, dementia, or encephalopathy:

- when routine EEG outcomes and neurological imaging are inconclusive to confirm diagnostic symptoms.

• to provide continuous monitoring for the early detection of an acute intracranial complication during cerebrovascular surgery (i.e., intracranial, carotid endarterectomy)

• to provide monitoring for detecting non-convulsive seizures in high-risk Intensive Care Unit (ICU) members.

Quantitative electroencephalography (QEEG) is considered experimental or investigational when performed for other indications such as, but not limited to, the following conditions, as there is insufficient scientific evidence in the peer reviewed medical literature to support its clinical usefulness:

• anxiety

• attention deficit disorder

• attention-deficit hyperactivity disorder

• autism spectrum disorders

• depression

• learning disorders

• schizophrenia

• substance abuse.


The following codes may be used to describe the various types of evoked potential testing, intraoperative neurophysiologic monitoring, or QEEG:

CPT Coding:


Visual evoked potential, screening of visual acuity, automated, with report


Visual evoked potential, testing for glaucoma, with interpretation and report


Auditory evoked potentials for evoked response audiometry AND/OR testing of the central nervous system; comprehensive


Auditory evoked potentials for evoked response audiometry AND/OR testing of the central nervous system; limited


Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs


Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in lower limbs


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


Central motor evoked potential study (transcranial motor stimulation); upper limbs


Central motor evoked potential study (transcranial motor stimulation); lower limbs


Visual evoked potential (VEP) testing central nervous system, checkerboard or flash


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


Central motor evoked potential study (transcranial motor stimulation); in upper and lower limbs


Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure)


Continuous intraoperative neurophysiology monitoring, from outside the operating room(remote or nearby) or for monitoring of more than one case while in the operating room, per hour (List separately in addition to code for primary procedure)


Electroencephalogram (EEG) during non-intracranial surgery (e.g. carotid surgery)


Digital analysis of electroencephalogram (EEG) (e.g. for epileptic spike analysis)


Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; initial hour of attendance by a physician or other qualified health care professional


Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; each additional hour of attendance by a physician or other qualified health care professional (List separately in addition to code for primary procedure)


Topographic brain mapping

HCPCS Coding:


Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure)

ICD-10 Diagnoses Codes That Support Medical Necessity for somatosensory-evoked potentials (95925, 95926, 95927, and 95938): (Effective 10/01/15)

C70.0 – C72.59

Malignant neoplasm of brain, spinal cord, cranial nerves, or other parts of central nervous system

C79.31 - C79.49

Secondary malignant neoplasm of brain and cerebral meninges; and other parts of nervous system

D33.0 – D33.4

Benign neoplasm of brain and other parts of the central nervous system

D43.0 – D43.8

Neoplasm of uncertain behavior of brain and central nervous system


Neoplasm of unspecified behavior of brain

G11.1 – G11.9

Hereditary ataxia




Multiple sclerosis


Syringomelia; syringobulbia

G95.20, G95.29, G95.9

Spinal cord compression

I63.031, I63.032, l63.033, I63.039

Cerebral infarction due to thrombosis of carotid artery

I63.131, I63.132, l63.133, I63.139

Cerebral infarction due to embolism of carotid artery

I63.231, I63.232, l63.233, I63.239

Cerebral infarction due to unspecified occlusion or stenosis of carotid arteries

I65.21 – I65.29

Carotid stenosis or occlusion

I71.01 – I71.9

Aortic aneurysm dissection

M47.011 – M47.029

Anterior spinal and vertebral artery compression syndromes

M48.01 – M48.07

Spinal stenosis

M50.00 – M50.03

Cervical disc disorder with myelopathy

M99.20 – M99.22

Subluxation stenosis of neural canal

M99.30 – M99.32

Osseous stenosis of neural canal

M99.40 – M99.42

Connective tissue stenosis of neural canal

M99.50 – M99.52

Intervertebral disc stenosis of neural canal

M99.60 – M99.62

Osseous and subluxation stenosis of intervertebral foramina

M99.70 – M99.72

Connective tissue and disc stenosis of intervertebral foramina

R40.20 – R40.2364


S14.0xxA – S14.0xxS

Concussion and edema of cervical spinal cord

S14.101A – S14.159S

Other and unspecified injuries of cervical spinal cord

S24.0xxA – S24.0xxS

Concussion and edema of thoracic spinal cord

S24.101A – S24.159S

Other and unspecified injuries of thoracic spinal cord

S34.01xA – S34.139S
S34.3xxA – S34.3xxS

Injury of lumbar and sacral spinal cord and nerves at abdomen, lower back and pelvis level

ICD-10 Diagnoses Codes That Support Medical Necessity for motor evoked potentials (MEPs) (95928, 95929, and 95939): (Effective 10/01/15)


Conversion disorder with motor symptom or deficit (hysterical paralysis)

F68.10 – F68.13

Factitious disorder

ICD-10 Diagnoses Codes That Support Medical Necessity for quantitative electroencephalography (QEEG) (95957, 95961, 95962, and S8040): (Effective 10/01/15)

F01.50, F01.51

Vascular dementia

F03.90, F03.91

Unspecified dementia

G40.101 – G40.919

Epilepsy and recurrent seizures

G93.40 – G93.49

Other and unspecified encephalopathy

I67.0 – I67.9

Other cerebrovascular diseases


Refer to section entitled POSITION STATEMENT.


Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products:

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Evoked Response Tests (160.10) located at

The following Local Coverage Determinations (LCDs) were reviewed on the last guideline reviewed date: Intraoperative Neurophysiology Monitoring (L33379) and Somatosensory Testing (L33958) located at


Acoustic neuroma (schwannoma): a benign growth near the brainstem.

Cerebellopontine angle: area of the brain between the cerebellum and the pons.

Meniere’s Disease: recurring attacks of vertigo associated with fluctuating tinnitus and deafness, and nausea and vomiting.

Otosclerosis: abnormal growth of bone near the middle ear that can result in hearing loss.

Saccule: The saccule and the utricle are parts of the balancing apparatus (membraneous labyrinth) located within the vestibule of the bony labyrinth of the ear. These use small stones and a viscous fluid to stimulate hair cells to detect motion and orientation; sensors for detecting angular or linear acceleration and head rotation.

True vertigo: a feeling of impulsion, rotation, oscillopsia with associated signs of nausea, vomiting, tinnitus, and deafness, staggering with relief by sitting or lying still.

Utricle: see definition of saccule.



None applicable.


  1. Agency for Healthcare Research and Quality; National Guideline Clearinghouse #8514 Head (trauma, headaches, etc., not including stress & mental disorders). Work Loss Data Institute. Head (trauma, headaches, etc., not including stress & mental disorders). Encinitas (CA): Work Loss Data Institute; 2011.
  2. American Academy of Neurology, Practice Parameter: The Usefulness of Evoked Potentials in Identifying Clinically Silent Lesions in Patients with Suspected Multiple Sclerosis, Neurology 2000, accessed 08/01/07.
  3. American Association of Neuromuscular & Electrodiagnostic Medicine. Recommended Policy for Electrodiagnostic Medicine, 2013; accessed at 08/02/16.
  4. American Society of Neurophysiological Monitoring. Isley MR, Edmonds HL Jr, Stecker M, American Society of Neurophysiological Monitoring. Guidelines for intraoperative neuromonitoring using raw (analog or digital waveforms) and quantitative electroencephalography: a position statement by the American Society of Neurophysiological Monitoring. J Clin Monit Comput 2009 Dec;23(6):369-90.
  5. Blue Cross Blue Shield Association Medical Policy – 7.01.58, Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring); 05/15.
  6. Blue Cross Blue Shield Association TEC Evaluations (1988, pp 110 – 118).
  7. Blue Cross Blue Shield of Florida Technology Assessment – Intraoperative Sensory Evoked Potentials (03/95).
  8. Centers for Medicare & Medicaid Services (CMS), NCD for Evoked Response Tests (160.10); accessed at 08/01/16.
  9. Vestibular Evoked Myogenic Potentials in Benign Paroxysmal Positional Vertigo (VEMP in BPPV) NCT01004913. Accessed 08/07/13.
  10. Vestibular Evoked Myogenic Potential: A New Device Propose NCT01132105. Accessed 08/07/13.
  11. Curthoys IS, Vulovic V, Manzari L. Ocular vestibular-evoked myogenic potential (oVEMP) to test utricular function: neural and oculomotor evidence. Acta Otorhinolaryngol Ital 2012;32:41-45.
  12. ECRI Institute, Sensory Stimulation for Reducing Time to Recovery from Coma or Vegetative State, 04/07.
  13. First Coast Service Options, Inc. (FCSO), Local Coverage Determination: Intraoperative Neurophysiology Monitoring (L33379); accessed at 08/01/16.
  14. First Coast Service Options, Inc. (FCSO), Local Coverage Determination: Somatosensory Testing (L33958); accessed at 08/01/16.
  15. Hayes, Inc., SEPS for Intraoperative Monitoring During Surgery for Scoliosis, update 02/07.
  16. Macdonald DB, et al. Intraoperative motor evoked potential monitoring - A position statement by the American Society of Neurophysiological Monitoring. Clin Neurophysiol. Dec 2013;124(12):2291-2316.
  17. Sharan A, et al, Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 15: electrophysiological monitoring and lumbar fusion. J Neurosurg Spine. 2014 Jul;21(1):102-5.
  18. Shimizu K, Murofushi T, Sakurai M, Halmagyi M. Vestibular evoked myogenic potentials in multiple sclerosis. J Neurol Neurosurg Psychiatry. 2000 Aug;69(2):276-7.
  19. Trivelli M, D’Ascanio L, Pappacena M, Greco F, Salvinelli F. Air- and bone-conducted vestibular evoked myogenic potentials (VEMPs) in otosclerosis: recordings before and after stapes surgery. Acta Otorhinolaryngol Ital. 2010 Feb;30(1):5-10.


This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 08/25/16.



Medical Coverage Guideline developed.


Reformatted and revised.


HCPCS coding changes.


Reviewed; removed reimbursement limitations; added statement regarding tests billed in the office setting.


Annual HCPCS update; consisting of addition of 95928 and 95929.


Scheduled review; no changes in coverage statement; no longer scheduled for routine review (NLR).


Revision consisting of the addition of clarification for ICD-9 diagnosis application.


Review, coverage statements maintained, guideline reformatted, references updated.


Revision consisting of adding fifth digit specificity for ICD-9 diagnosis code 433.1.


4th Quarter HCPCS coding update: ICD-9 diagnosis code 724.02 revised, ICD-9 code 724.03 added for 95925, 95926, and 95927.


Revision; related ICD-10 codes added.


Annual HCPCS coding update: added 95938 and 95939.


Revision to Position Statement to include information regarding quantitative electroencephalography; add relevant coding; update references.


Annual CPT/HCPCS coding update; added 95940 and 95941 and G0453; revised 95961 and 95962; deleted 95920.


3rd Quarter CPT coding update: added 0333T; Program Exceptions section updated.


Revision to add position statement for vestibular evoked myogenic potentials (VEMP); references updated.


Revision to the Billing/Coding section.


Revision; ICD9 and ICD10 coding sections updated.


Revision: ICD-9 Codes deleted.


Revision; Guideline title, description, position statements, billing/coding, and references updated.


ICD-10 coding update; codes l63.033, l63.133, & l63.233 added.


Annual CPT/HCPCS update. Added 0464T; revised 0333T.

Date Printed: June 26, 2017: 01:20 AM