Neurology & Pain Management Coding Alert

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

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: Your neurologist performs a 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 the code requires a minimum of four positions. If you use fewer than four positions, append modifier 52 (Reduced services) for an accurate reflection of the service performed.

Modifier side note: Some coders get caught in the trap of whether to submit modifier 52 or modifier 53 (Discontinued procedure) with some claims, but it's not always worth worrying about.

"The point I always like to make is that fretting over 52 versus 53 really doesn't matter because you have to send documentation in with both," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CodeRyte Inc. coding analyst and coding review teacher. "Those modifiers don't have an automatic mathematical formula applied to them, so the payer will review and decide on the payment."

Exception to the 1-unit rule: You can once again take your billing cue from a descriptor when you consider 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 per irrigation, reporting each aural and thermal stimulation is critical for fair reimbursement, says Timothy C. Hain, MD, a neurologist with Northwestern University's Feinberg School of Medicine in Chicago.

Watch Your Pay for Multiple Units of 92547

You can bill multiple units of +92547 (Use of vertical electrodes [list separately in addition to code for primary procedure]), but that doesn't mean you-ll always be paid.

What you can expect: Depending on what equipment you are using, you can bill 92547 four or five times, experts say. With some equipment, for example, you can only bill four times if you don't record a vertical component for one of the ENG tests.

Reporting 92547 multiple times doesn't guarantee reimbursement for each unit, however. Some coders say their practice never initially receives more than one unit of reimbursement for 92547.

Payer stance: Prior to 2005, the American Medical Association asked that you report 92547 once per visit because the code carried such a high value relative to the ENG codes you paired it with (92541-92546). Payers might 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.

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

In the September 2004 CPT Coding Assistant, the AMA says that you can report 92546 only when the provider completes testing using a rotational chair. Even with this clarification, many coders still tread into dangerous territory by reporting 92546 to describe other types of rotational testing, such as active head rotation.

What to do: 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 your physician uses 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.