Otolaryngology Coding Alert

Dizziness in migraine is not as common as you think with the numerous symptoms that come with it.

Many patients of otolaryngology who complain of migraine headaches also complain of dizziness. But although these two conditions may coexist in considerable proportion for most cases, many coders have yet to draw the line between migraine and dizziness when billing them.

Background: "About 10 percent of dizziness clinic patients have vertigo caused by migraine, and patients with migraine are more likely to suffer from Ménière's disease and benign paroxysmal positional vertigo (BPPV)," explains Stephen P. Cass, MD, Associate Professor in the Department of Otolaryngology at the University of Colorado Health Sciences Center in Denver in an article published by ENTtoday titled Migraine-Associated Dizziness Is Elusive To Diagnose. Do you have a hard time telling the boundaries between these signs and symptoms? Pinpoint the appropriate migraine diagnosis using these pointers from the experts.

Symptoms Tell A Deeper Story

Even physicians do not have internationally accepted criteria for migraine-associated dizziness. When a patient who has migraine presents to the office with complaints of dizziness, usually, the otolaryngologist would diagnose it by looking at symptoms for a migraine headache (346.9x), which include:

• unilateral throbbing pain lasting from four to 72 hours, along with
• nausea/vomiting (787.01);
• photophobia (368.13); and/or
• abnormal auditory perception (388.40).

Additionally, vertigo (780.4) takes place often in patients who have had migraine episodes without aura (346.1x), but it can also occur in migraine with aura (346.0x).

The physician should also take a thorough history of the patient's migraine. For instance, he should determine if the dizziness had occurred during a headache-free interval, or if it came with symptoms such as spontaneous rotational vertigo, motion sickness (994.6), and visual motor sensitivity.

Keep Your Vestibular Tests Report From Spinning Out Of Control

When the patient shows vestibular signs, the ENT may order a vestibular test (92541-92548). Usually a qualified otolaryngology technician would perform the technical portion of the evaluation, while the ENT, PA, or nurse practioner provides direct supervision and later furnish the interpretation.

Definition: Vestibular tests are tests of function. It aims to determine if something is wrong with the vestibular portion of the inner ear. If dizziness is not caused by the inner ear, it might be caused by disorders of the brain, by medical disorders such as low blood pressure, or by psychological conditions such as anxiety.

When ordering vestibular tests, make sure the physician documents the service's professional component, which include clinical decision- making and other active participation in the delivery of the service, according to CMS Transmittal 84. The documentation should include such details as:

• the technician's name and professional identity;
• the specific tests the physician ordered; direct supervision and interpretation by the nonphysician practitioner (NPP) or physician.
• Direct supervision means the physician or NPP under which the test is being billed is in the office suite when the test is performed. The physician or NPP need not be in the room with the patient and the technician.

Example: An otolaryngologist orders a qualified technician to perform an oscillating tracking test (92545, Oscillating tracking test, with recording). The physician directly supervises, and interprets the result. On your claim, you would report the following:

• 92545-TC (Technical component) for the technician's technical contribution billed under the physician or NPP that provided the direct supervision;
• 92545 appended by modifier 26 (Professional component) for the otolaryngologist's interpretation under her own NPI.

When reporting 92545, you should limit the units to one, says Dr. Phyllis Schaffer-Cohen, AuD, FAAA, an audiologist in Englewood, N.J. Why? In 92545, the audiologist asks the patient to move only his eyes. The audiologist does not do anything but instruct while the patient stays still in one spot.

What happens: This test comprises two types: the smooth pursuit and the saccadic test. The smooth pursuit test evaluates the ability of the patient to keep a moving visual target registered on the fovea. The patient watches a moving target as it moves back and forth in a smooth pendular fashion. The saccadic test evaluates the ability of the patient to find a moving target and tests certain CNS neural integrators. A computer calculates the gain, and compares it to age matched norms.