Pediatric Coding Alert

Pediatricians are under pressure to screen their patients for hearing problems, but do not always know how to use the CPT codes that apply. One of the problems is that some codes pay very well, but require equipment that the pediatrician doesnt have and isnt likely to get. If the pediatrician or his or her biller tries to bill these codes inappropriately, even though the cause is ignorance and not greed, the insurance company could realize that there is a problem during an audit. But by knowing the differences between the various audiometry codes, pediatricians can avoid this problem.

First, there is a difference between a hearing screen and a diagnostic hearing test, says Susan Beam, CCC/A, an audiologist with Genesis Health Care System at Bethesda Hospital in Zanesville, Ohio. A screen is a test on an apparently normal baby or child to find out if there might be a problem, she explains. If the child fails the screen, further testing is done.

In some states, including Ohio, all newborns are screened without any actual test at all, but with a paper form filled out by each new parent. If there are any indications of risk prematurity or various prenatal illnesses, for example then the baby is called in for a screening.

On infants, the screening test we use is an otoacoustic emission test, says Beam. The code for this test is CPT 92587 (evoked otoacoustic emissions; limited [single stimulus level, either transient or distortion products]). In the normal healthy ear, a noise is produced, she explains. We have found that we can evoke that noise. A little probe put into the ear sends two sounds simultaneously. The ear gives an echo that the probe picks up and the computer analyzes. With transient noise, test results can be achieved with a softer stimulus.

If the baby fails the 92587 screen, Beam brings the baby in a month later for a repeat. Then, if the infant fails that test as well, the baby goes to the childrens hospital for an auditory evoked potential test. This test is not a screen. In fact, it doesnt test hearing at all. Instead, it examines the nerve pathway from the cochlea back to the brain stem. The CPT code for this test is 92585 (auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system). During the test, electrodes are attached to each mastoid or earlobe, to the forehead, and to the top of the head. Then, earphones (or little foamy plugs) are used to deliver a stimulus either clicks or tones. Many hospitals do this test on babies, but some dont. A pediatrician may need to refer a child to a neurologist before this test will be done. I do this test for neurologists, explains Beam.

Both 92587 and 92585 are fairly specific tests not usually done by primary care pediatricians. Another kind of screening is performed that is more familiar to pediatricians pure tone screening. This is the kind of test Beam does at preschools. Im in a non-standard environment not in my booth when I do those tests, she says. Its too loud to do any kind of threshold testing, so instead I pick one level. For example, Beam will pick 25 decibels, and then test how well the child can hear different frequencies 500, 1,000, 2,000 at that volume. The code used for this kind of screening is 92551 (screening test, pure tone, air only).

Codes 92551 and 92552 are also the codes most likely to be used by primary-care pediatricians who do hearing screens. Threshold testing code 92552 (pure tone audiometry [threshold]; air only) reveals how softly something can be heard at different frequencies. The audiometric threshold is the level at which the patient can hear a frequency 50 percent of the time. For example, Beam sets the audiometer at 500 hertz, and then turns the volume down to see what the decibel threshold is below which the child hears that frequency only 50 percent of the time. Hearing loss may be only at high or low frequencies.

Another kind of hearing screen is detection of speech. I do these tests depending on the age of the child, says Beam. Code 92555 (speech audiometry threshold) is used for testing to see if the voice can be heard at different frequencies, but 92556 (speech audiometry threshold; with speech recognition) goes a step further. If the child is three years old, says Beam, speech recognition testing can be done. I use body parts, the audiologist says. I say, Show me your nose, and I get softer and softer with different body parts.

Now, there are pediatricians who do speech testing, but without an audiometer. You cannot bill any of these audiologic function tests 92551-92598 unless you are using calibrated electronic equipment, says Beam, citing CPTs introduction to the codes. With the audiometer, the testers voice is adjusted to reflect specific values. If I get 25 on my decibel dial, I have to know that 25 is what is coming out, says Beam. Just talking to a child wont give you an accurate result.

The average conversational tone, says Beam, is between 45 and 60 decibels. A child may be able to hear 45 decibels and answer appropriately and still have a hearing loss, the audiologist explains. Maybe its a high-frequency hearing loss.

Tuning forks have their value, but once again, this is not a calibrated device, says Beam. There is a test that involves putting the end of the fork in the middle of the forehead and asking the child which ear he hears the tone in. The problem with this test is that it doesnt tell how loudly the child hears the tone, says Beam. And how loud it is partly depends on how hard you hit the tuning fork.

Finally, what hearing screening code is used when the parent just says, My child isnt hearing well? At this point, says Beam, pediatricians usually refer the child to an audiologist for a complete audiometric evaluation. The code for this is 92557 (comprehensive audiometry threshold evaluation and speech recognition), which is codes 92553 (pure tone audiometry [threshold]; air and bone) and 93556 (speech audiometry thresholds; with speech recognition) combined. Code 92557 does not include other hearing codes, however, such as 92567 (tympanometry [impedance testing]), which is a test of how well the eardrum responds to pressure and is frequently done as part of follow-up of otitis media.