Article - Billing and Coding: Vestibular Function Testing (A56497)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim that lacks the necessary information to process that claim.CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, 3.4.1.3 Diagnosis Code RequirementsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Vestibular Function Testing L34537.Appropriate ICD-10-CM codes must be submitted with each claim. Claims submitted without such evidence will be denied as not medically necessary.It is not enough to link the procedure code to a payable ICD-10-CM code. The diagnosis or clinical suspicion must be present for the procedure to be paid, and the patient's medical record must document that the coverage criteria in this policy have been met. Covered services must meet general community standards of appropriate medical care. For example, extremely mild symptoms of very short duration may not justify procedures or testing, even though a listed ICD-10-CM symptom might superficially be met. Inclusion of certain "not otherwise specified" codes does not mean that any other associated disorder is covered.Repeat testing on a regular basis, in the absence of the resumption of symptoms, is not warranted. A few conditions may require testing on multiple days due to variably acute symptoms, such as benign positional vertigo, which varies with inner ear canal stones. However, in this case, isolated testing with CPT92542 is usually sufficient, and within several episodes, a diagnosis should be established.CPTcodes 92541 and 92542 are more likely to be medically necessary for follow up of disorders, likely secondary to canal block pathology. For this purpose, there may be testing at several visits, at intervals, for evaluation of interval change and symptoms.Scope of PracticeDiagnostic procedures 92541-92542 and 92544-92548 may be performed only by licensed audiologists with a physicians order; by a licensed physician, preferably with certification by the American Board of Medical Specialties in Otolaryngology, Neurology or Otology/Neurology; or other providers licensed to practice medicine under the personal supervision of an appropriate physician as described in the Code of Federal Register (CFR).Basic AudiometryCPTcode 92552 or 92553 will be covered if ordered and performed in conjunction withVFT. CPTcode 92557 will also be covered if ordered and performed in conjunction with Vestibular Function Testing (VFT), instead of CPTcode 92553, when the speech recognition component of the CPTcode 92557 is reasonable and necessary in the diagnosis or treatment of an individual Medicare beneficiary (e.g., Vestibular Schwannoma). No other hearing tests will be covered, when performed in conjunction with VFT for the diagnosis of balance problems.CPTcode 92557 - This is a comprehensive audiometry evaluation, which includes a battery of tests comprised both of the elements of threshold evaluation (hearing threshold levels at various frequencies presented by both air and bone conduction) and speech audiometry, including both speech reception and speech recognition testing. CPTcode 92557 includes the elements of CPTcodes 92553 and 92556; therefore, these codes cannot be billed on the same date of service in addition to CPTcode 92557.SummaryCPTcodes 92542, 92544, 92545, 92546, and 92548 are billable once per day, and repeated analysis or confirmation of findings within the session is considered part of 1 test. Note, for example, that CPTcode 92542 specifically requires 4 or more positions tested in order to bill for 1 unit (per CPTdefinition).CPTcode 92537 is intended to report a complete caloric vestibular testing procedure that includes bilateral performance of bithermal irrigation (i.e.,one warm andone cool irrigation for each ear). Fewer irrigation procedures require a different method of reporting according to what was done. For 3 irrigations (e.g., irrigation of both ears using monothermal irrigation of 1 ear and bithermal irrigation of the contralateral ear), code 92537 and report with modifier 52. Monothermal irrigation (i.e., irrigation of both ears with either cool or warm irrigation) is reported once with CPTcode 92538. If a single ear is irrigated with a single method of irrigation (cool or warm) code 92538 is reported once with modifier 52,as described in the CPTInsiders View January 2016.CPTcode 92547 may be billed multiple times as required by other medically necessary tests. Since the same electrodes are typically used for several serial tests, billing more than 6 per day would be atypical.CPTcodes 92531, 92532, 92533, and 92534 for vestibular function tests, without electrical recording are considered bundled physical examination codes by Centers for Medicare and Medicaid Services (CMS), have Relative Value Units (RVUs) of zero, and are not payable.