Otolaryngology Coding Alert

When otolaryngologists test patients with vertigo to determine the source of their dizziness, the examinations fall into two general categories: recorded (electronystagmography, or ENG) and non-recorded. Medicare will reimburse the former but not the latter. So increasingly, otolaryngologists either send patients to a vertigo center for recorded testing, or if they have the equipment in their own offices, perform the test there.

Patients complaining of dizziness are often referred by their primary care physicians, and may pose a diagnostic dilemma for otolaryngologists, because vertigo can occur due to a variety of factors originating in the inner ear or nervous system, says Edward F. Babb, MD, CPC, an otolaryngologist and coding consultant in NJ. We are attempting to determine the etiology (cause) of the vertigo, he says. By taking the patients history, positional testing and caloric testingstimulation of the inner ear via a thermal effect by warm and cold applications of either air or water, you may be able to say the problem is inner ear.

The procedures Dr. Babb describes are known as vestibular function tests. Before the advent of ENG, otolaryngologists performed these tests without electrical recording and billed for the exam as follows:

92531: spontaneous nystagmus, including gaze

92532: positional nystagmus

92533: caloric vestibular test, each irrigation (binaural,
bithermal stimulation constitutes four tests)

Because the caloric tests typically involve stimulating both ears with warm and cold water or air, code 92533 would take four units, two for left and right ear and two for warm and cold water or air.

Note: Although Medicare no longer pays for these tests, some private payers still do, so it is important to check with your carrier before performing non-recorded vestibular functions tests.

The fallout from Medicares decision to no longer reimburse non-recorded tests impacts on otolaryngologists performing the Dix-Hallpike test, a non-invasive positional procedure used to accurately determine if a patient has benign paroxysmal positioning vertigo, or BPPV. In this disorder, some of the very small crystals of calcium carbonate located in the inner ear are dislodged and float down into one of the three canals of the inner ear. The crystals are trapped in the canal, and when the person moves in certain ways, the crystals move and give the person the sensation of spinning, i.e., vertigo. However, the Dix-Hallpike test is not a Medicare-reimbursed procedure, and neither is the procedure most often used to treat BPPV, known as the canalith repositioning procedure. This technique is used to clear the crystal out of the canal and deposit it back into the part of the inner ear where it belongs.

In the past, the canalith repositioning procedure could be billed using code 97112 (neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception). However, Medicare now does not recognize the diagnosis of vertigo for this procedure.

Watch Units Box When Billing for ENG Tests

Increasing numbers of physicians are using electronystagmography to determine if the patients dizziness originates in the inner ear. Typically, an ENG test is performed at a facility, although some otolaryngologists have ENG equipment in their offices. Electrodes attached to the patient induce nystagmus, the movement of the eye that occurs in patients with vertigo.

According to Dr. Babb, ENG is a much more definitive way of measuring the functioning of the inner ear. A typical ENG involves several procedures and is coded as follows:

92541: spontaneous nytagmus test, including gaze and fixation nystagmus, with recording

92542: positional nystagmus test, minimum of four positions, with recording

92543: caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes four tests)
with recording

92544: optokinetic nystagmus test, bidirectional,
foeval or peripheral stimulation, with recording

92545: oscillating tracking test, with recording

92547: use of vertical electrodes (list separately in
addition to code for primary procedure)

CPT notes that 92547 should be used in conjunction with codes 92541-92546 (sinusoidal vertical axis rotational testing). This presents a curious coding dilemma. Should 92547 be billed only once (as is most commonly done) or as many as five times, depending on how many of the procedures require electrodes to be attached, which would appear to be more technically correct from a strict coding standpoint?

So far, the issue has not been resolved by either CPT or Medicare. However, Beth Sutton, a coder in the office of Paul Antalik, MD, an otolaryngologist in Pittsburgh, PA, bills the 92547 only once. Her office includes an audiologist with ENG equipment.

For any ENG the audiologist does in this office, we bill 92541 through 92545. They are all necessary to rule out central nervous system causes for dizziness, and to help determine if dizziness is caused by inner ear, she says. All our ENGs are done by the audiologist and all five of those codes are used. Sutton adds that in her office, 92547 is coded if the audiologist needs to observe and measure vertical eye movement.

When performing the caloric portion of the ENG, special attention must be paid to the units box. For example, it is not unusual for the test to include warm, cold and ice stimulation to both ears. In that case, six units would have to be indicated in the units box on the HCFA 1500 claim form.

If the problem is determined not to be caused by the inner ear, the patient will be referred to a neurologist, Sutton says.