Fife, Terry D. MD, FAAN, FANS
Accurate coding is an important function of neurologic practice. This section of CONTINUUM is part of an ongoing series that presents helpful coding information along with examples related to the issue topic. Tips for diagnosis coding, evaluation and management coding, procedure coding, or a combination are presented, depending on which are most useful for the subject area of the issue.
This article is intended to provide guidance on the current vestibular testing codes and will include Current Procedural Terminology (CPT) codes 92540 to 925448, 95992, and 92585. The table below lists the codes and the relative value units for each code.
CPT Code Description Modifiera Medicare RVU (Nonfacility)b Units Allowed per Procedure by CMSc Bundling Issues
92540 Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional and foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording Global RVU W 1.50 1 Do not report 92540 in conjunction with 92541, 92542, 92544, or 92545. If billing 92541, 92542, 92544, and 92545 on the same day use 92540 instead. If not performing all four codes on the same day, one may bill the individual CPT codes, but use of the -59 modifier is advised.
RVU PE 1.39
RVU MP 0.05
92541 Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording Global RVU W 0.40 1 Do not report 92541 in conjunction with 92540 or the set of 92542, 92544, and 92545.
RVU PE 0.45
RVU MP 0.02
92542 Positional nystagmus test, minimum of 4 positions, with recording Global RVU W 0.33 1 Do not report 92542 in conjunction with 92540 or the set of 92541, 92544, and 92545.
RVU PE 0.43
RVU MP 0.02
92543 Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes 4 tests), with recording Global RVU W 0.10 6 Bill for each irrigation up to a maximum of six if icewater is used. (Except for hospital outpatient prospective payment systems, where payment is adjusted for billing one time only.)
RVU PE 0.34
RVU MP 0.02
92544 Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording Global RVU W 0.25 1 Do not report 92544 in conjunction with 92540 or the set of 92541, 92542, and 92545.
RVU PE 0.39
RVU MP 0.02
92545 Oscillating tracking test, with recording Global RVU W 0.23 1 Do not report 92545 in conjunction with 92540 or the set of 92541, 92542, and 92544.
RVU PE 0.37
RVU MP 0.02
92546 Sinusoidal vertical axis rotational testing Global RVU W 0.29 4
RVU PE 2.78
RVU MP 0.02
92547 Use of vertical electrodes N/A RVU W 0.00 1 to 8 Report this code in addition to the code(s) for the primary procedures for each vestibular test performed (92541-92546). If no tests are conducted that use electrodes, then this code should not be billed according to one local coverage determination.d
92548 Computerized dynamic posturography Global RVU W 0.50 1
RVU PE 2.66
RVU MP 0.02
95992 Canalith repositioning procedure N/A RVU W 0.75 1 Effective 1/1/11, this may be billed as a stand-alone procedure, unbundled from the evaluation and management code.
RVU PE 0.44
RVU MP 0.05
92585 or 92700e Vestibular-evoked myogenic potentials (VEMPs) Global RVU W 0.50 1
RVU PE 3.31
RVU MP 0.02
CPT = Current Procedural Terminology; RVU = Relative value unit; CMS = Centers for Medicare & Medicaid Services; W = Work; PE = Practice expense; MP = Malpractice.
a Modifiers: CPT codes 92547 and 95992 have no modifiers.
b Non-facility price is the payment to privately owned facilities and medical practices; facility prices (not listed) are very similar for these codes and would apply to facilities owned by or part of hospitals.
c The number of units that can be billed and paid per procedure may vary among the contracted Medicare carriers. Non-Medicare insurance companies may allow more units to be billed per procedure than listed, but this is variable.
d Spectral Medical Consulting.1
e There is no code specifically for VEMPs, but they are done with auditory-evoked brainstem response equipment so most facilities use 92585, whereas some recommend using CPT code 92700 “Unlisted otorhinolaryngological service or procedure” for VEMP testing.
History and Ongoing Uncertainties
As much as in any area of reimbursement for medical care, the codes related to vestibular testing have undergone repeated changes in recent years, and it appears that further changes are yet to come. As a result, it seems impossible to write an article on billing and coding that will not become at least partially obsolete within months. The changes seem to be part of what is happening in medicine in general, with a bitterly divided government, cost-constraint efforts by the Centers for Medicare & Medicaid Services (CMS) and private insurance, and a multitude of competing interests influencing payment policy. Most of the discussion in this article pertains to Medicare because their policies are more transparent. Furthermore, many private insurance companies choose to follow Medicare payment policies.
CPT Codes 92540 to 92545
The codes 92541, 92542, 92543, 92544, and 92545 are the traditional electronystagmography (ENG) or videonystagmography (VNG) codes. A few years ago, CMS, in a stated desire to simplify the codes, created a new code (92540) intended to bundle four of the codes together and leaving 92543 (caloric vestibular testing) as a stand-alone code (see below). At first, the 2010 ENG/VNG code changes did not allow more than one component code (92541, 92542, 92544, and 92545) to be billed together. That is, one could be paid for 92541 but not for both 92541 and 92542 together if performed on the same day.
The American Academy of Audiology, the American Speech-Language-Hearing Association, the American Academy of Otolaryngology-Head and Neck Surgery, and the AAN petitioned to change the National Correct Coding Initiative (NCCI) edits that were mistakenly placed on the individual vestibular CPT codes 92541, 92542, 92544, and 92545. In response, effective October 1, 2010, if two or three of these codes are reported for the same date of service by the same provider for the same beneficiary, the NCCI-associated modifier -59 may be used and payment is permissible. Hence, the CPT codes 92541, 92542, 92544, and 92545 may now be billed separately even if only one, two, or three of these procedures are performed on the same date of service by the same provider for the same patient. Nevertheless, if all four codes (92541, 92542, 92544, and 92545) are performed, then the “bundled” code 92540 should be used in order to receive payment from Medicare and most commercial payers.
CPT Codes 92543, 92546, 92547, and 92548
CPT code 92543 is a test of caloric irrigation (air or water) and may be billed for each caloric test performed. Most ENG/VNG studies entail bithermal caloric testing: right warm, left warm, right cool, left cool. Sometimes, if responses are very poor, bilateral ice water irrigations may be indicated (eg, to assess for bilateral vestibular loss). Therefore, up to six units of this procedure may be submitted for payment.
CPT code 92546 has been revised in recent years to disallow autorotational testing or eye movement recordings on a swiveling office chair. Now it is clearly described as a computer-controlled vertical axis rotational chair with recording. It may be billed as one unit. Although some may argue that multiple frequencies and step velocity tests are done, at present no additional compensation is available for the added testing. Given the high cost of a computerized rotational chair for vestibular testing, the break-even point may exceed the reasonable life expectancy of the apparatus.
CPT code 92547 is a code for placement of vertical electrodes. In the early days of ENG, many facilities used electrodes to record only horizontal eye movements. It then became clear that the eyes move vertically as well and that there was added value in recording vertical eye movements, so 92547 was made an add-on code, billable once. In 2005, revisions led to a reduction in payment to about 12% of its original reimbursement level, but it can be billed more than once (usually 4 to 6 times per routine study).2 A local coverage determination (LCD) by Palmetto GBA indicated that if electrodes are not used in the study (as with VNG), this code cannot be billed at all.1
CPT code 92548 is for computerized dynamic posturography. Although not strictly a vestibular test, it is often performed in conjunction with vestibular tests to clarify the degree and possibly the mechanistic cause of imbalance. Recently, one Medicare administrator, Palmetto GBA, issued an LCD detailing a description of computerized dynamic posturography (92548) that seemed to describe the proprietary family of posturography products made by a single manufacturer. In mid-February 2012, in response to concerns this promoted a monopoly, Palmetto GBA revised the LCD to resume coverage of code 92548 broadly defined as posturography. A description of posturography has not been written at the time of this writing. Although CMS currently provides payment for posturography, the majority of private health insurance payers deny payment for posturography, considering it to be investigational.
CPT Modifiers -25 and -59
-25 is a modifier that means there is a “significant, separately identifiable evaluation and management service”3 (office visit) by the same physician on the same day as the procedure or other service. Hence if one sees patient for migraine headache and a vestibular procedure is also done, then -25 modifier would clarify that these are separate services for which payment is justified. Meanwhile, -59 modifier indicates there is “a distinct procedural service.”4 This modifier might be used, for example, if codes 92541 and 92542 were performed together on the same day to indicate that they are separate procedures.
Who May Perform Vestibular Tests?
Codes 92540 to 92548 may be performed only by licensed audiologists with a physician’s order or by personnel employed “incident to” a physician. When performed by personnel not qualified as described above, the procedures are not covered by Medicare according to an LCD by Palmetto GBA updated most recently on January 1, 2010.2 It should be noted that Palmetto GBA is only one of a number of Medicare Administrative Contractors (MACs) that make local coverage decisions, and each MAC may opt for its own coverage decision.
CPT Code 95992
In 2009, CMS introduced CPT code 95992 (canalith repositioning procedure(s) [eg, Epley maneuver, Semont maneuver] per day) on the basis of strong evidence regarding its effectiveness in treating benign paroxysmal positional vertigo.
CMS surprised many, however, by not following the recommendation of the American Medical Association RVS Update Committee and instead assigning the code to be “bundled” with the evaluation and management (E/M) service that it would accompany. That is, they considered it to be included in the payment for the new or follow-up visit, and the code was not reimbursed as a separate procedure. Then, in the 2010 Physician Fee Schedule Final Rule, CMS changed 95992 from “bundled” to “not recognized for payment under Medicare.” Because of feedback from physicians, CMS changed the status of 95992 effective January 1, 2011, to make it “active,” so that physicians and physical therapists could also perform and receive payment for canalith repositioning using 95992. Medicare currently does not reimburse audiologists for performing the canalith repositioning procedure because it is not considered a diagnostic test.
CPT code 95992 may be billed with other codes, such as 92540 or 92542, using the modifier -59, or with an E/M code (eg, 99213) by using the -25 modifier.
CPT Code 92585 or 92700
Currently no CPT code is specifically designated for vestibular myogenic-evoked potentials (VEMPs), which has prompted some to advocate for use of an unlisted code (92700).
VEMPs are a type of auditory-evoked response and can be performed on many standard evoked-potential devices simply by opening the filters, adjusting the amplifier, and placing the recording electrodes over a muscle. These changes were not specifically approved by the US Food and Drug Administration (FDA), however, so in 2008 the FDA prohibited manufacturers of evoked-potential devices from selling the software application for VEMP testing. In trying to comply with FDA-mandated recalls of the equipment software, a number of manufacturers sent their customers a software “update” intended to delete the software, permitting them to continue to perform VEMP studies. The recall was considered a marketing correction until the FDA received and cleared a new 501(k) premarket notification application.
Despite the FDA issue with manufacturers, clinicians are not required to discontinue using VEMP testing when it is medically indicated.