Pediatric Coding Alert

Question: Our pediatric office just began providing tympanometry. Do insurers require certain diagnoses to cover the procedure? Do most insurance companies bundle the procedure with the office visit?

Virginia Subscriber

Answer: CPT does not bundle tympanometry (92567, Tympanometry [impedance testing]) with a well visit. In fact, the section notes for 99381-99394 state that you should report procedures with their own codes separately from the preventive medicine services. That being said, for payers that follow the National Correct Coding Initiative (NCCI), the edits include a minor E/M with most procedural codes. Although most pediatric patients are not on Medicare, many private payers follow the payer's policies and require modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) appended to E/M codes to indicate that on the day a procedure or service was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond other services provided or beyond the usual preservice and postservice care associated with the performed procedure. Therefore, to bill an E/M, insurers will probably require that the office visit constitute a separately identifiable service from the tympanometry.

For example, an established patient with serous otitis media comes in for a follow-up visit. The pediatrician performs a low-level E/M (99212, Office or outpatient visit for the E/M of an established patient ...) but is unsure if the child's condition has cleared and therefore performs a tympanogram (92567). You should report the office visit (99212) appended with modifier -25 to indicate that the exam is a significant and separately identifiable service because it led to the decision to perform the test. Link 99212-25 and 92567 to the serous otitis diagnosis code (381.10, Chronic serous otitis media, simple or unspecified).

For a new patient, the service is clearly separate. For example, a new patient whom another physician already diagnosed with serous otitis media presents to a pediatrician who believes the child may have hearing loss and performs impedance testing (92567) to determine if the eustachian tube is functioning normally. The results are negative. Therefore, you should use the serous otitis ICD-9 code for both services, with modifier -25 attached to the appropriate level of E/M.

Most payers cover 92567 for a variety of hearing and ear problems. You should check with your carriers for specific rates. For instance, in 2001, Medicaid nationally averaged $14.39 for impedance testing and Virginia Medicaid paid $15 for 92567, according to an American Academy of Pediatrics' survey. That compares to a current Medicare rate of $47.09, based on the Medicare Physician Fee Schedule, which gives 1.28 relative value units to 92567. Although pediatricians usually do not have Medicare patients, you can use these rates as a benchmark for other insurers.