Neurology & Pain Management Coding Alert

Reporting 92546 for standard ENG testing?  AMA says not so fast

If you-re confused about how many units you can report for each electronystagmography (ENG) and videonystagmography (VNG) service you perform, you-re not alone. Check our expert advice to make sure your coding for vestibular testing is on the level.

Report Only 1 Unit for Most Tests

As a general rule of thumb, remember that for 92541, 92542, 92544 and 92545, you-ll reach your billing limit at one unit per patient visit.

Example: You perform positional nystagmus test with multiple positions including supine with the head extended dorsally, left, right and sitting. You should take your lead from the descriptor for 92542 (Positional nystagmus test, minimum of 4 positions, with recording) and only report one unit, because a minimum of four positions is required. If you use fewer than four positions, append modifier 52 (Reduced services) for an accurate reflection of the service performed. 
        
Exception: You can once again take your billing cue from the descriptor of 92543 (Caloric vestibular test, each irrigation [binaural, bithermal stimulation constitutes four tests], with recording), and report up to four units. In this test, the neurologist irrigates the ear with warm and then cold water. If she performs the irrigation on each side (binaural) with dual temperatures (bithermal), you should report all four irrigations.

Since Medicare pays just $27 per irrigation, reporting each aural and thermal stimulation is critical for fair reimbursement, says Timothy C. Hain, MD, neurologist with Northwestern's Chicago Dizziness and Balance.

Add On Pay for Multiple Units of 92547
 
You may be feeling dizzy trying to keep up with recent rule changes for add-on code +92547 (Use of vertical electrodes [list separately in addition to code for primary procedure]). Prior to 2005, the American Medical Association asked that you report 92547 once per visit, because the code carried such a high value ($45.18) relative to the ENG codes you pair it with (92541-92546).

A drastic 2005 cut by CMS lowered the value for 92547 to just $5.31 but also opened up the opportunity to bill for use of vertical electrodes with each test.

What you can expect now: Depending on what equipment you are using, you can bill 92547 four or five times, says Robert Henderson, JD, chief executive officer of Vestibular Technologies in Tampa, Fla. -With our equipment, for example, you could only bill four times because we don't record a vertical component for one of the ENG tests,- Henderson adds.
 
Even with a seriously deflated payment of $21.24 (4 units) or $26.55 (5 units), it may not always be easy to get reimbursed for each unit. According to Barbara Knep, office manager of Neurology Group of North Jersey in Clifton, her practice is never able initially to receive more than one unit of reimbursement for 92547.

Payers can always cite the AMA's earlier statements as reason to limit one unit of 92547 per visit. If you run across this denial, consider arguing to the payer that the high payment rate--which was the reason for the limit--has been drastically slashed.

Mistake: You should not bill for 92547 in conjunction with VNG. Because VNG uses video to record and measure the patient's eye movement, instead of vertical electrodes, 92547 doesn't apply.     

Don't Report Active Head Rotation with 92546

The most common error for ENG/VNG testing, and the most probable to raise suspicions from the Office of Inspector General, involves sinusoidal vertical axis rotational testing (92546).

In the September 2004 CPT Coding Assistant, the AMA says that 92546 can only be properly reported when testing is done using a rotational chair. Even with this clarification, many coders are still treading into dangerous territory by using this code to describe other types of rotational testing, such as active head rotation. 

Alternative: You should code active head rotation instead using 92700 (Unlisted otorhinolaryngological service or procedure). While reimbursement for an unlisted-procedure code is questionable, steering clear of OIG's radar could prove to be far more valuable.

If you are using a rotational chair, consult your individual carriers- guidelines for reporting. Many, including Medicare, will determine that only one unit per visit is appropriate, while others, such as northwest carrier Fortress, allow you to bill for each velocity per direction, up to three units per direction.