Summary & Overview
CPT 5200F: Neurosurgical Referral Consideration for Intractable Epilepsy
CPT code 5200F indicates that a clinician has, within the previous three years, considered referring a patient to a neurosurgical specialist to evaluate candidacy for surgical treatment of intractable epilepsy. Nationally, this measure matters because timely recognition of surgical candidacy can affect long-term outcomes for patients with medically refractory seizures and supports multidisciplinary management pathways.
Key payers in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of the code’s clinical intent and service context, benchmarks and utilization patterns where available, and relevant policy or coverage considerations affecting neurosurgical referral for epilepsy. The publication also outlines expected sites of service and service line implications for outpatient neurology practices and epilepsy centers.
This summary is intended for clinicians, billing professionals, and policy analysts seeking a clear national overview of CPT code 5200F, its clinical purpose, and the payment and care coordination context surrounding referral evaluation for epilepsy surgery.
Billing Code Overview
CPT code 5200F documents that a provider has, within the past three years, considered referring a patient to a neurosurgical specialist to evaluate candidacy for surgical therapy to treat intractable epilepsy. This code captures a documented clinical consideration of neurosurgical referral as part of epilepsy care.
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Service type: Specialist referral consideration / care coordination related to evaluation for epilepsy surgery
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Typical site of service: Outpatient neurology clinic or other ambulatory care setting where epilepsy management and referral decisions occur
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A typical patient is an adult or adolescent with medically refractory focal or generalized epilepsy who continues to experience disabling seizures despite trials of two or more appropriate antiseizure medications. During an outpatient neurology follow-up visit, the neurologist documents a focused review of seizure frequency, prior medication trials, prior diagnostic testing (EEG, video EEG, brain MRI), and functional impact. The clinician records that, within the past three years, they have considered referral to a neurosurgeon or epilepsy surgical program to evaluate candidacy for surgical therapy (for example, resective surgery, laser ablation, or neuromodulation such as vagus nerve stimulation or responsive neurostimulation). Typical workflow steps include chart review, discussion with the patient and family about risks and benefits, coordination of referral to a tertiary epilepsy center or neurosurgical specialist, and scheduling of pre-surgical evaluations (long-term EEG monitoring, neuropsychological testing, and epilepsy imaging) as indicated.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure | When an E/M visit is distinct from other services rendered the same day while documenting consideration of surgical referral |