Otolaryngology Coding Alert

Question: United Healthcare has begun to deny CPT 92568 as inclusive in 92569, even though CPT shows it as a separate code and procedure. Can you suggest some information to assist in an appeal of this denial?

Virginia Coder

Answer: According to the 2000 CPT Manual and also current Medicare guidelines, CPT codes 92568 (acoustic reflex testing) and 92569 (acoustic reflex decay test) are not bundled services, says Emily Hill, PA, CPC, a coding and reimbursement specialist in Wilmington, N.C., and a member of the AMA's RVU Committee, Correct Coding Policy Committee and CPT-5 Project.

Since the carrier is denying payment stating that 92568 is included in procedure code 92569, they have, as other carriers, developed their own particular coding combinations. It would not be unreasonable to ask for a detailed explanation of their decision to bundle the two codes, since CPT and the National Correct Coding Initiative (CCI) have not done so.

Denial of these claims definitely should be appealed, Hill says. To support the fact that two separate and distinct procedures were performed, medical record documentation should be sent to the carrier. Hill also recommends that copies of CPT rules and the CCIs should be included with the documentation, adding that it also may help to contact the appropriate specialty society to find out if any policies or statements regarding the use of these two codes have been issued.

Still, the carrier may not alter its position. Hill suggests that one of the two procedures be billed with modifier -59 (distinct procedural service) to indicate that the procedure/service was distinct and independent from the other service performed on the same day, but this, too, does not guarantee payment from many carriers.