Neurology & Pain Management Coding Alert

Preparing an unlisted-procedure code claim can make your head spin. But with the Epley maneuver, it may be your best bet for reimbursement. Check out what our experts recommend for reporting this long-used service.

"What took them so long?" That's the question many neurologists have asked about the American Academy of Neurology's (AAN) recent move to create a guideline governing the use of the canolith repositioning procedure (CRP), also known as the Epley maneuver after its creator, Dr. John Epley. The procedure consists of a series of gentle movements designed to treat benign paroxysmal positional vertigo (BPPV). This practice guideline provides support for procedures like the Epley maneuver and may make it easier to get payers to pay for the therapeutic procedure -- even if it doesn't have a designated CPT code. Now it's up to you to know how to best report your neurologist's use of the procedure.

BPPV is caused by small calcium carbonate stones that have moved from the vestibule of the inner ear into the semicircular canals. This is where your sense of balance rests. The presence of these stones stimulates the nerves in the inner ear and causes a tremendous spinning sensation that can cause nausea and unsteadiness. "The maneuvers move the calcium crystals out of the sensing tube and into another inner chamber of the ear, from which they can be absorbed," according to the AAN.

"The good news is that this type of vertigo is easily treated," says guideline author Terry D. Fife, MD, of the University of Arizona College of Medicine and Barrow Neurological Institute, in a press release issued by the AAN. "Instead of telling patients to -wait it out- or having them take drugs, we can perform a safe and quick treatment that is immediate and effective."

There is a valid HCPCS code for canolith repositioning: S9092 (Canolith repositioning, per visit). However, Medicare does not recognize the "S" HCPCS codes, so you shouldn't report them to Medicare. Most Blue Cross/Blue Shield and other commercial payers will recognize the S codes, but such HCPCS codes have no established relative value units (RVU), so you may still encounter payment issues.

Alternative: "Code 92700 (Unlisted otorhinolaryngological service or procedure) is recommended by some payers as the best for the Epley, even though it is an unlisted procedure code," says Michelle Logsdon, CPC, CCS-P, of Falcon Practice Management in River, N.J.

Furthermore, for some payers, "92700 is only payable with the BPPV diagnosis code [386.11, Benign paroxysmal positional vertigo] and it must be clearly documented in the record," says Logsdon. "You will need to send a cover letter to the insurance carrier explaining the Epley, and send along the medical records when requested by the payer once the claim has been received."

Requesting payment for the Epley may not be worth the effort for some practices. "The new guideline may positively impact the reimbursement process," Logsdon says, as the current process is time consuming and includes appeals and phone calls to the carrier. "Medicare used to reimburse quite well, $133.01 in 2006," but Horizon BCBS only paid $25, Logsdon adds.

Now Medicare has significantly reduced the reimbursement. Some practices are considering this procedure on a cash basis if the treatment is considered non-covered by the payer and the patient has been given advance notice.

Double-check: Some Medicare carriers, including the Noridian, Palmetto and WPS MAC jurisdictions, have local coverage determination (LCD) coverage policies that direct providers to report 97530 (Therapeutic activities, direct [one-on-one] patient contact by the provider [use of dynamic activities to improve functional performance], each 15 minutes) for the Epley maneuver rather than the unlisted CPT code. Remember this physical medicine CPT code is based on time, and the procedure documentation should include your provider's face-to-face time during the CRP.

Best bet: Check with the payer if 92700, S9092 or 97530 is the correct code they want reported for the Epley maneuver.