Otolaryngology Coding Alert

Question: Our carrier has begun to deny 92568 as inclusive in 92569 although CPT shows it as a separate code and procedure. How can I appeal this?

Virginia Subscriber

Answer: According to the 2000 CPT manual and current Medicare guidelines, 92568 (acoustic reflex testing) and 92569 (acoustic reflex decay test) are not bundled services, says Emily Hill, PA, CPC, an independent coding and reimbursement specialist in Wilmington, N.C., and a member of the American Medical Associations Relative Value Units Committee, Correct Coding Policy Committee and CPT-5 project.

Because the carrier is denying payment stating that 92568 is included in procedure code 92569, they have, as have 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 because CPT and the national Correct Coding Initiative (CCI) have not bundled these codes.

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 CCI 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.