How To Use CPT Code 95921

CPT 95921 describes the testing of autonomic nervous system function, specifically cardiovagal innervation (parasympathetic function). This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 95921?

CPT 95921 can be used to evaluate the function of the autonomic nervous system, specifically the cardiovagal innervation (parasympathetic function). This code is used when the provider performs two or more tests to assess the patient’s heart rate response to deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio.

2. Official Description

The official description of CPT code 95921 is: ‘Testing of autonomic nervous system function; cardiovagal innervation (parasympathetic function), including 2 or more of the following: heart rate response to deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio.’

3. Procedure

  1. The provider attaches ECG leads to the patient’s chest, arms, and legs.
  2. The patient is asked to take several slow, deep breaths while the ECG records their heart rate response.
  3. The provider then instructs the patient to perform the Valsalva maneuver, either forcefully exhaling with closed mouth and nostrils or exhaling into a tube.
  4. The ECG records the patient’s heart rate response to the Valsalva maneuver.
  5. For the 30:15 ratio test, the patient stands up, and the ECG records the heart rate response.
  6. The provider calculates the 30:15 ratio by dividing the R-R interval at beat 30 by the R-R interval at beat 15.

4. Qualifying circumstances

CPT 95921 is used to evaluate the cardiovagal innervation (parasympathetic function) of the autonomic nervous system. It is typically performed on patients who require assessment of heart rate response to deep breathing, Valsalva ratio, and 30:15 ratio. The provider must perform two or more of these tests to qualify for CPT code 95921.

5. When to use CPT code 95921

CPT code 95921 should be used when the provider performs two or more tests to evaluate the cardiovagal innervation (parasympathetic function) of the autonomic nervous system. These tests include heart rate response to deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio. If only one test is performed, modifier 52, Reduced services, may be appended to the code.

6. Documentation requirements

To support a claim for CPT 95921, the provider must document the following information:

  • Patient’s diagnosis or reason for testing
  • Specific tests performed, including heart rate response to deep breathing, Valsalva ratio, and 30:15 ratio
  • Date and time of the testing
  • Results of each test and any abnormalities observed
  • Signature of the provider performing the tests

7. Billing guidelines

When billing for CPT 95921, ensure that the provider performs two or more tests to evaluate the cardiovagal innervation (parasympathetic function) of the autonomic nervous system. Modifier 52 may be appended if only one test is performed. If reporting only the professional component, modifier 26 should be appended. If reporting only the technical component, modifier TC should be appended, unless the hospital provided the technical component. Do not append modifiers to the code when reporting a global service.

8. Historical information

CPT 95921 was added to the Current Procedural Terminology system on January 1, 1997. The code was later revised on January 1, 2010 to include the specific tests for cardiovagal innervation (parasympathetic function).

9. Examples

  1. A patient undergoes testing of autonomic nervous system function to evaluate their cardiovagal innervation. The provider performs the heart rate response to deep breathing, Valsalva ratio, and 30:15 ratio tests.
  2. During an evaluation, the provider assesses the patient’s autonomic nervous system function by performing the heart rate response to deep breathing, Valsalva ratio, and 30:15 ratio tests.
  3. A patient with suspected autonomic dysfunction undergoes testing, including heart rate response to deep breathing, Valsalva ratio, and 30:15 ratio tests, to evaluate their cardiovagal innervation.
  4. The provider performs the heart rate response to deep breathing, Valsalva ratio, and 30:15 ratio tests to assess the patient’s autonomic nervous system function.
  5. During a comprehensive evaluation, the provider evaluates the patient’s cardiovagal innervation by performing the heart rate response to deep breathing, Valsalva ratio, and 30:15 ratio tests.
  6. A patient with a history of autonomic dysfunction undergoes testing, including heart rate response to deep breathing, Valsalva ratio, and 30:15 ratio tests, to monitor their cardiovagal innervation.

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