Category Type(Required)Non-CORECOREFFS and FFS BillingReading Neurologist(Required) Date of Service(Required) MM slash DD slash YYYY Patient InformationName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Patient Chart #(Required) General Diagnosis (ICD) Code(Required) EEG Recording InformationRoutine Performed?(Required)YesNoDOS - Day 1(Required) MM slash DD slash YYYY Day 1 Recording Time (HR:MIN)(Required) DOS - Day 2 MM slash DD slash YYYY Day 2 Recording Time (HR:MIN) DOS - Day 3 MM slash DD slash YYYY Day 3 Recording Time (HR:MIN) DOS - Day 4 MM slash DD slash YYYY Day 4 Recording Time (HR:MIN) DOS - Day 5 MM slash DD slash YYYY Day 5 Recording Time (HR:MIN) Total Recording Time(Required)0-2 hr2-12 hr12-26 hr26-40 hr40-60 hr60-72 hr72-84 hr84+ hrVideo Recording InformationDay 1 - Recording Time (HR:MIN)(Required) Day 2 - Recording Time (HR:MIN) Day 3 - Recording Time (HR:MIN) Day 4 - Recording Time (HR:MIN) Day 5 - Recording Time (HR:MIN) Total Recording Time(Required)0-2 hr2-12 hr12-26 hr26-40 hr40-60 hr60-72 hr72-84 hr84+ hrMonitoringMonitoring Service Performed(Required)Continuous (every 1 hr or less)Intermittent (every 1-2 hrs)Notes
