Primary Care Coding Alert

Question: A patient reported to our provider complaining of brief episodes of vertigo that are triggered by changes of body and head positions. Our provider went ahead with something that he documented as a Dix-Hallpike maneuver. From that, the provider offered a diagnosis that was benign paroxysmal positional vertigo (BPPV). What codes do I use to document this?

AAPC Forum Participant

Answer: For a definitive diagnosis of BPPV, you should use H81.1- (Benign paroxysmal vertigo). But you should ask your provider for greater specificity, as the code requires a fifth character to indicate whether the BPPV originates from the patient’s right ear (1), left ear (2), an unspecified ear (0), or whether it is bilateral (3).

There is no specific CPT^® code for the Dix-Hallpike maneuver, which involves your provider observing the patient for eye movements after laying the patient down on a bed from a sitting position to a supine position with the patient’s head lying over the edge of the bed at a 45-degree angle. To document it, you will use 92542 (Positional nystagmus test, minimum of 4 positions, with recording). That’s because the maneuver is typically considered a positional component of 92542.

Pro Coding Tip: No matter how many times your provider performs either maneuver, you will only report one unit of 92542 per patient, per day.