Primary Care Coding Alert

For many students in the fall, "back to school" also means back to the doctor's office. Virtually all public and private institutions require periodic vision and hearing tests to evaluate whether the student's physical development is progressing along a normal timeline. In most instances, these assessments are reported in addition to other services provided during the same visit. However, professional coders must be alert to a number of important factors -- whether the service is diagnostic instead of screening, for instance, determines which code is reported.

Vision Screening Code Is Often Overlooked

 
FPs were delighted in 2000 when a new CPT code was added to describe basic vision screening, often referred to as Snellen or wall chart tests. "Before 99173 (screening test of visual acuity, quantitative, bilateral) was implemented, practices had no specific code to report these services," says Imee Tanseco, CPC, coding supervisor for Argus Medical Management LLC, a Long Beach, Calif., firm that provides coding and billing services for primary care and pediatric practices.
 
She notes that many practices have yet to adopt this code or use it consistently. "I find that many family physicians continue to use the unlisted-procedure code to describe vision screening (99199, unlisted special service, procedure or report). They're not used to having a specific code and are still reporting it incorrectly," she says.
 
Another common error, Tanseco says, occurs when family practice coders assume vision screening is bundled into E/M services performed the same day. "This isn't the case, and CPT is very clear on this issue in notes following the code description. 99173 should be reported in addition to the office or preventive-care visit."
 
For instance, if a girl entering kindergarten is seen for her annual checkup and the physician checks her eyesight, coders should report either 99383 (initial preventive medicine; late childhood [age 5 through 11 years]; new patient) or 99393 (periodic preventive medicine; late childhood [age 5 through 11 years]; established patient) along with 99173. Modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is not appended to the E/M code because no edits govern these codes.
 
Coders should recognize that 99173 is clearly defined only as a screening exam. When acuity is measured during a general ophthalmologic service or an E/M service of the eye, this service is then a diagnostic examination and not a screening test.  In these cases, testing visual acuity is considered part of the general ophthalmological or E/M service and is not separately reported using 99173.

Vision Screening Has No Published RVUs

 
While coders consider the addition of 99173 good news, they also point out a significant disappointment: The new code has been assigned zero relative value units (RVU). This means the Medicare program has attached no fees for dedicated vision screening. However, coding professionals like Tanseco say this is likely to change as more physicians report the code.
 
"Practices also should note that they will be paid if they are reporting vision screening performed on patients covered by the Child Health Development Program," Tanseco says. "However, services would not be reported with the usual CPT codes. In California we use PM160, as required by MediCal, to report vision screenings." Coders should ask local carriers for the coding policies in their state.

Understand Differences Between 92551 and 92552

   
As with vision screening, one primary code is used to report screening tests for hearing -- although many coders report being confused about audiologic function tests 92551 (screening test, pure tone, air only) and 92552 (pure tone audiometry [threshold]; air only).
 
Although both definitions use similar language, there can be no doubt that 92551 is the screening test that would be reported by most family practices, says Jeanne Barno, audiologist with a two-physician practice in Fort Pierce, Fla. "The screening code is simply a pass/fail assessment and is most often administered with patients exhibiting no symptoms of hearing loss."
 
But services described in code 92552 add the element of threshold testing, she explains. "This reveals how softly a tone can be heard at different frequencies. Because threshold testing quantifies the levels at which hearing fails, it is considered a diagnostic test."
 
The screening study is conducted with earphones or insert earphones, when only pure tones are used to gauge hearing. "No transducer other than air is used during a screening," she says. "Services described by 92551 do not include other common audiological testing methods -- for instance, when the spoken word is used to elicit responses or when oscillators are placed on the mastoid bone behind the ear and vibrations are measured."
 
During a screening assessment, the practitioner sets up the hearing test at a single intensity, 25 decibels (dB). Tones are then emitted at different frequencies, which the patient may or may not be able to hear. If the patient fails the screening evaluation, he or she would be referred to an otolaryngology or other specialty practice, where an audiologist would perform diagnostic studies to quantify the hearing loss.
 
Note: Besides being used with young patients, these evaluations are often performed with adults working in environments where standards set by the Occupational Safety and Health Administration (OSHA) must be met.
 
One additional code from the audiologic function series in CPT is commonly used by family physicians. Services described in code 92567 (tympanometry [impedance testing]) may also be performed to measure pressure on the far side of the ear drum. Results may indicate a medical condition that affects hearing, e.g., 381.81, dysfunction of Eustachian tube.