Otolaryngology Coding Alert

Call on 92540 when you should describe a test combo.

If you've been confused as to whether an audio technician may perform and can report vestibular testing codes 92540-92548, you're not alone. Coders have hotly debated this matter, as well as when to report the umbrella code 92540. The good news is we've got answers to clear up the confusion.

Know When To Attach Modifiers PC, TC

Case 1: Your audio technician performs videonystagmography (VNG) 92540, 92543 to investigate the function of a Medicare patient's vestibular system within the inner ear. What can you charge on your claim?

Solution 1: Keep in mind that audio technicians are not credentialed by Medicare, so the technical portion of VNG study should be billed "incident to" the physician, nurse practitioner, physician assistant or audiologist who is supervising the audio technician. Do not assume that private payers and your state Medicaid follows the same incident to rules as Medicare. You need to contact each of your private payers and your state Medicaid payer and get in writing their billing requirements for audio technicians.

In this regard, you do not attach modifier TC (Technical component) to 92540 (Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording) and 92543 (Caloric vestibular test, each irrigation [binaural, bithermal stimulation constitutes 4 tests], with recording) when reporting VNG testing performed by an audio technician for Medicare patients. In addition, make sure you pay attention to certain rules for reporting an audio tech's services. For one, you can only use audio techs when the procedure performed has no professional thought process for the part that the technician is performing: you should report only codes that have PC and TC component (professional and technical component division) associated with them, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.

In short, technicians can only perform the TC under direct supervision of a physician. The codes include:

• 92540-92548 -- Vestibular evaluation tests, wherein an audio technician may perform the technical component while a doctor, nonphysician provider (NPP), or audiologist performs the professional component.
• 92585 -- Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive
• 92587 -- Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)
• 92588 -- Evoked otoacoustic emissions; comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies)

Special case: Audio techs may perform 92567 (Tympanometry [impedance testing]) under direct physician supervision since the service is mostly automatic, as indicated in CMS Transmittal 84 (www. cms.gov/Transmittals/Downloads/R84BP.pdf). This means that technicians do not require the skills of an audiologist, NPP, or physician to interpret the test results, provided the audiologist, NPP, or physician is responsible for all clinical judgment and for the appropriate provision of the service.

Exception: Code 92557 (Comprehensive audiometry threshold evaluation and speech recognition [92553 and 92556 combined]) has no technical component, so services provided by an audio tech cannot be reported for this service.

Mark Four Components That Make Up 92540

Case 2: The physician performs positional nystagmus test with multiple positions including supine with the head extended dorsally, left, right and sitting. Should you report the standard vestibular evaluation code 92540?

Solution 2: Take your lead from the descriptor for 92542 (Positional nystagmus test, minimum of 4 positions, with recording) and report one unit of the procedure because the code requires a minimum of four positions. If you use fewer than four positions, you should append modifier 52 (Reduced services) to indicate that the procedure was not completed in its entirety.

A basic vestibular evaluation includes four components:

• a spontaneous nystagmus test (92541, Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording)
• a positional nystagmus test (92542)
• an optokinetic nystagmus test (92544, Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording)
• an oscillating tracking test (92545, Oscillating tracking test, with recording)

You may report each component individually according to its CPT® assignment, but if the physician performs all these components together, you would report the service using a single code: 92540.

However, if the provider performed one to three of the tests (92541, 92542, 92544 or 92545), you should append modifier 59 (Distinct procedural service). For instance, it is not unusual for 92541 and 92542 to be performed on the same date of service, so they can be billed as 92541 and 92542-59 for the same date of service if those were the only two test components of 92540 performed, explains Debbie Abel, Au.D., director of reimbursement and practice compliance, American Academy of Audiology. These two are often done in tandem to diagnose BPPV, she adds.

Background: When the bundled code first went into effect on Jan. 1, 2010, the rule stated that if 1-3 of the tests were done (92541, 92542, 92544 or 92545), they would be billed individually. This turned out to be an error -- prompting a parenthetical note in the codebook. It took until Oct. 1, 2010 to have the NCCI edit lifted.