Otolaryngology Coding Alert

Physicians have limited use of available CPT codes. Find out why.

When reporting for audiologist's services, don't forget that Medicare prohibits audiologists from billing for treatment services. They are only allowed to bill for diagnostic services. However, otolaryngologists may bill for therapeutic services. CPT manual lists 10 codes for cochlear implant services.

Don't rack your brains yet. Fortunately, you have ways to work within this guideline. Check out these frequently asked questions (FAQs) and bare some sense on how you should tackle that claim for hearing loss treatment.

What CPT Codes Do I Have In My Cache?

CPT lists 10 codes which you may use for cochlear implant services:

92506 -- Evaluation of speech, language, voice, communication, and/or auditory processing;

92507 -- Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual;

92601 -- Diagnostic analysis of cochlear implant, patient younger than 7 years of age; with programming;

92602 -- Diagnostic analysis of cochlear implant, patient younger than 7 years of age; subsequent reprogramming;

92603 -- Diagnostic analysis of cochlear implant, age 7 years or older; with programming;

92604 -- Diagnostic analysis of cochlear implant, age 7 years or older; subsequent reprogramming;

92626 -- Evaluation of auditory rehabilitation status; first hour;

92627 -- Evaluation of auditory rehabilitation status; each additional 15 minutes (List separately in addition to code for primary procedure);

92630 -- Auditory rehabilitation; prelingual hearing loss;

92633 -- Auditory rehabilitation; postlingual hearing loss.

Again, Medicare limits coverage of an audiologist's services to diagnostic testing only. Additionally, speech language pathologists (SLPs) may only use 92506, 92507 and 92508 (Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals) for treatment services, including auditory rehabilitation, according to Medicare. This means that Medicare will not pay audiologists when they report 92506, 92507, or 92508. On the other hand, think of 92507 as an "umbrella" code that covers everything SLPs do. The otolaryngologist can do and report any of these codes.

What Options Do I Have Besides 92507?

Depending on the type of cochlear implant service rendered by your physician, you can explore using any of the 10 codes previously listed. For instance, if the service involves cochlear implant fitting and programming, you would bill 92603 for patients older than 7 years; 92601 for patients 7 years and younger.

HCPCS' L codes also have a role to play for cochlear implant supplies. You would use L8619 (Cochlear implant external speech processor and controller, integrated system, replacement) to report replacement, and L7500 (Repair of prosthetic device, hourly rate [excludes V5335 repair of oral or laryngeal prosthesis or artificial larynx]) to report repair services.

Important: Make sure you contact the payers to check which CPTs/HCPCS they will accept. Doing so could save you time in awaiting your payment.

Example: A 37-year-old patient who's had a cochlear implant surgery presents to the office for fitting and programming of his device. He visits 93 days after his surgery. In this case, you would report 92603. Medicare covers this service as long as it is provided outside the 90-day period following surgery. Services within 90 days are included in the global payment for the surgical procedure.

What Medicare Official Directive Should I Refer To?

Medicare's specific policy on cochlear implant services appears on an article in MLN Matters, a publication of the Centers for Medicare and Medicaid Services' (CMS) Medicare Learning Network, and describes Medicare coverage for CI services that became effective April 4, 2005. (For a copy of this article, you may email editor Claire Gamboa at cgamboa@codinginstitute.com.)

The article states: "CMS will cover treatment of bilateral pre- or post-linguistic, sensorineural, moderate-to-profound hearing loss for individuals with hearing test scores equal to or less than 40 percent correct in the best aided listening condition on tape-recorded tests of open-set sentence recognition ... Additionally, CMS will cover cochlear implants of individuals with open-set sentence recognition test scores of greater than 40 percent to less than or equal to 60 percent correct, where the device was implanted in an acceptable clinical trial/study."

Do Private Payers Follow Medicare Rule?

Some do; some don't. Nonetheless, each patient's health plan has a specific policy regarding coverage that may differ from the others. Regardless of the general policy of the health insurance carrier, you should check out the patient's contract to determine coverage.

You should also note that some states mandate cochlear implant (CI) coverage, as in the case of Wisconsin which, in May 2009, became one of the first states to require insurance companies to cover the cost of CIs for children 18 years old or younger.