Otolaryngology Coding Alert

If you are used to picking and choosing which electronystagmography (ENG) tests apply to your patient -- and getting reimbursed for each of them -- you may not like the changes 2010 has brought to bear on vestibular testing.

Read on for the skinny on what you can report, and the limitations you may face, when treating patients with balance disorders.

Starting in 2010, four ENG tests are bundled into a single CPT code: 92540 (Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of four positions, with recording, optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording).

Slant: Streamlining is not always a welcome change. Forcing these four tests into a bundle is "not the way clinical practice is done," explains Steven C. White, PhD, CCC-A, director of Health Care Economics and Advocacy at the American Speech-Language-Hearing Association (ASHA) in Rockville, Md.

Per CPT and the Correct Coding Initiative (NCCI) new code 92540 encompasses the following codes:

• 92541 -- Spontaneous nystagmus tests, including gaze and fixation nystagmus, with recording;

• 92542 -- Positional nystagmus test, minimum of 4 positions, with recording;

• 92544 -- Optokinetic nystagmus test, bidirectional,foveal or peripheral stimulation, with recording; and

• 92545 -- Oscillating tracking test, with recording..

Impact: For patients, you won't be able to report any combination of two or more of the above codes for the same date of service.

Don't miss: Calorics testing (92543, Caloric vestibular test, each irrigation [binaural, bithermal stimulation constitutes 4 tests], with recording) was left out of the bundle. You may report 92543 along with any other singular vestibular code.

The introduction of 92540 means your options for performing and reporting ENG tests are more limited -- at least for the time being.

Problem: There are times when only two tests would be indicated rather than completing the four procedures that comprise the new bundle, says Debbie Abel, AuD, director of reimbursement for the American Academy of Audiology in Reston, Va.

Example: For a patient with suspected benign paroxysmal positional vertigo (386.11), an audiologist may order only 92541 to evaluate spontaneous eye movement and 92542 to determine which head positions may evoke lightheadedness, offers Robert C. Fifer, PhD, director of Audiology and Speech-Language Pathology at University of Miami's Mailman Center for Child Development.

If you think you can use a modifier to override the edits that prohibit any two or more of the 92541, 92542, 92544, 92545 set from being reported together on the same day, think again. You cannot use a modifier to override these CCI edits, since all of the sets have either "0" or "9" in the modifier column. These bundles conform to CPT's parenthetical instructions following 92540-92542 and 92544.

View: "With what happened with this code [92540],we've got a mess on our hands," laments Fifer. During 92540 discussions, physicians in the field had insisted that the individual codes remain -- the restrictions on reporting more than one code was "not what was intended," Fifer says. "A number of audiology, ENT, and neurology leaders are working together to try to correct this" by appealing to the CPT panel for a change, he adds.

In the meantime, no easy answer exists for an encounter in which a patient receives more than one of thebundled tests but not all four tests included in 92540.

52 conundrum: Appending 52 (Reduced services) to 92540 when you perform only two or three of the bundled tests isn't the easy fix you might think. "The reimbursement of the [92540] bundle is about 50 percent of what all four codes are together," laments Abel. "To append 52 will result in next to nothing in terms of reimbursement."

Short-term fix: If you don't complete the entire 92540 battery, however, you may not have an alternative. If physicians do less than the entire battery, 52 may be the only option available to them to account for the relative value units (RVUs) "until we can resolve the issue of reporting the individual codes together," says Fifer. "In the long run, my guidance would be not to use 52 because we fought to keep the individual codes ... the use of 52 is intended to be a short-term, temporary measure until we can clarify the language with CPT."

While a revision to lift the restriction on reporting more than one code may eventually come around, waiting it out by holding claims or planning on appeals would be a nightmare, comments Abel.

Instead: Check with your non-Medicare payers for guidance on how to report these services, Abel suggests.

Also, stay in close communication with Medicare carriers. The 92540 code may be recognized at different times by different carriers, according to when each uploads their new fee schedule, points out Fifer. Thus, you may still be able to report combinations of the individual vestibular codes until that time.