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Internal Medicine Coding Alert

Complex Diagnosis Drives Management of Presbycusis

Published on Tue Jan 01, 2002

Age-related hearing loss, presbycusis, also called presbyacusis (388.01), is estimated to occur in 30-35 percent of adults aged 65-75 and 40-50 percent of those over the age of 75. Nearly every internist faces the need to accurately diagnose this common condition. Because it can be multifactorial, correct diagnosis of presbycusis is critical in determining the best treatment. Furthermore, appropriate codes must be assigned to avoid any liability resulting from misdiagnosis. Because there are no medical therapies or drugs to improve presbycusis as such, reimbursement depends on thorough and complex diagnosis and, thus, precise coding of each diagnostic procedure.

Excluding Other Conditions
 
Presbycusis generally affects both ears equally, with common symptoms being: difficulty distinguishing words from each other, greater difficulty hearing womens speech than mens, more problems when there is background noise, and tinnitus (388.3x), cautions Warren Henderson, MD, an internist at the Clark-Holder Clinic in La Grange, Ga. The complex mechanisms of the ear make careful diagnosis critical, often meaning that an internist must invest more time during the E/M visit. Internists must make sure that this time is appropriately noted in order to justify the level of E/M code reported.
 
Routine physical examinations reveal no specific physical abnormalities associated with presbycusis. Otoscopy and tuning fork tests are not itemized, as they come under the 99201-99215 E/M coding series. Diagnosing presbycusis is a process of exclusion and should be made only after evaluating and ruling out other possible causes. These could be as simple as cerumen impaction (380.4) or as complex as otosclerosis (387.x) or cholesteatoma (385.3x). Other tests blood tests for autoimmune hearing loss, CT scan or MRI to rule out anatomic abnormalities, tests of central auditory processing to rule out abnormal sound processing may require referral to a specialist.
 
Moreover, the behavioral manifestations of moderate-to-severe hearing loss often resemble those of cognitive decline (confusion, disorientation, delirium, and dementia), such as the symptoms of Alzheimers disease (331.0).
 
If other causes have been excluded, internists can perform two basic sets of audiometric tests:

  pure tone audiometry, air only (92552), or air and bone (92553)
  speech audiometry threshold (99255), or with speech recognition (92556).
 
If both 92553 and 92556 are performed on the same visit, however, the correct code is 92557 (comprehensive audiometry threshold evaluation and speech recognition). This comprehensive evaluation forms the cornerstone of diagnostic testing for presbycusis diagnosis.

Two Basic Types of Presbycusis
 
Presbycusis is generally designated as one of two types: sensorineural or conductive, requiring different diagnostic codes as well as treatments. Most often presbycusis is due to sensorineural causes (389.1x) disorders of the inner ear, specifically the cochlea, or the auditory nerve. This type of hearing loss generally appears gradually, often from the cumulative effects of repeated exposure to daily noises and other sounds. Sensorineural losses may also be congenital or the result of an illness, such as meningitis (320.x, 321.x, 322.x) or the side effects of some medicines (aspirin and certain antibiotics).
 
Sometimes, however, presbycusis is a conductive hearing disorder (389.0x), meaning that the loss results from outer- or middle-ear problems, which are often mechanical in nature and can be corrected by medicine or surgery. There are various causes for conductive hearing loss, including otitis media (382.x) and otosclerosis (387.x). The latter is best handled by referral to a specialist. Sensorineural or conductive disorders may in fact contribute to presbycusis. However, Kathy Pride, CPC, CCS-P, coding supervisor for the Martin Memorial Health Group in Stuart, Fla., cautions, I have found that coders often use 389.9 [unspecified hearing loss] when 388.01 [presbyacusis, hearing loss caused by advancing age] is more appropriate.
 
Presbycusis may also be caused by changes in the blood supply to the ear due to various types of heart disease such as hypertension (401.x-405.x), vascular conditions caused by diabetes (250.x), or other circulatory problems. Diagnosis and treatment of any such underlying causes is critical, and the internist can initiate treatment.

Elderly Patients Illustrate Complexity of Presbycusis
 
An elderly male patient presents as basically healthy and mentally alert. He does, however, complain of progressive hearing loss, with particular difficulty understanding words when there is a high level of background noise. This can interfere with his effectiveness at meetings or ability to engage in conversations in public areas. He may have a history of noise exposure such as in the armed services, hunting, or industrial occupations. Audiometry (92557) may reveal a high-frequency sensorineural hearing loss. The mans speech discrimination score may be normal except in the presence of background noise. Because the patient has been shown to be otherwise healthy, the internist must first rule out treatable conditions such as otitis media or otosclerosis.
 
After confirming a diagnosis of presbycusis (388.01), the internist may discuss the importance of reducing noise exposure, use of ear plugs, hearing aids, training in speech reading, and assistive devices such as telephone amplifiers. If the internist spends more than 50 percent of the visit counseling on disease management, then E/M coding for the visit may be based on time, which must be documented.

Avoid Coding Missed Steps
 
Opportunities for coding missed steps can occur at a number of points in evaluating and managing the patient with presbycusis. Because the diagnosis is a process of first excluding other conditions that could account for the hearing loss, coders need to determine all of the laboratory or other diagnostic procedures the internist has used. For example, if cerumen impaction has been found, did the internist perform a removal procedure (69210)? Finally, the complexity of the evaluation and management needs to be carefully noted because this can often involve detailed discussion with the patient, family or caregiver about the techniques and equipment that can help to compensate for the hearing loss due to presbycusis.

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