The information in this Supplemental Instructions Article (SIA) contains coding or other guidelines that complement the Local Coverage Determination (LCD) for Audiologic and Vestibular Function Testing. The LCD can be accessed through our contractor Web site at www.NGSMedicare.com. It can also be found on the Medicare Coverage Database at www.cms.hhs.gov/mcd.
Coding Guidelines:
General Guidelines for claims submitted to Carriers or Intermediaries or Part A or Part B MAC: Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
A claim submitted without a valid ICD-9-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.
The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.
Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines (for outpatient services): An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04,
Medicare Claims Processing Manual, Chapter 30, revised 09/05/2008, for complete instructions.
Services not meeting medical necessity guidelines should be billed with modifier -GA or -GZ.
The -GA modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny a specific service as not reasonable and necessary and they
do have an ABN signed by the beneficiary on file. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Fiscal Intermediary or Part A MAC, occurrence code 32 and the date of the ABN is required.
The -GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they
have not had an ABN signed by the beneficiary.
If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier.
Audiological diagnostic tests may not be billed "incident to" the services of a physician or nonphysician practitioner.
Audiologist's may be paid for the global service when they perform both the technical and professional components of services that have both components.
Audiologist's may be paid for the technical component of an audiological test when they perform only the technical component and a physician or qualified nonphysician practitioner provides the professional component of services that have both components.
The global component of audiological diagnostic tests may be paid when furnished personally by a qualified physician or qualified nonphysician practitioner.
The audiometric tests listed in the LCD imply the use of calibrated electronic equipment.
Other hearing tests (such as whispered voice, tuning fork) are considered part of the general otorhinolaryngologic services and are not reported separately.
Audiologic function tests (CPT codes
92550, 92552-92557, 92561-92588) refer to testing of both ears.
The bilateral modifier, "50" is never appropriate to use. Using modifiers "RT" and "LT" on separate lines is also not appropriate. Modifiers "RT" or "LT" should be used only if a unilateral service is performed.
The bilateral concept does not apply to vestibular function tests (CPT codes
92540-92547). Using a RT, LT or 50 modifier is never appropriate.
An initial evaluation of a hearing problem must be indicated as such in the appropriate documentation record for electronic claims or on the CMS-1500 claim form for Medicare Part B and on the CMS-1450 for Medicare Part A.
Use CPT code 92700 to report a Lombard test. "Lombard test" must be reported in the appropriate documentation record for electronic claims or on the CMS-1500 claim form for Medicare Part B and on the CMS-1450 for Medicare Part A.
For dates of service 12/31/2009 and prior, CPT code 92569 is payable, if medically necessary. However, 92569 should not be billed if 92568 is negative.
When CPT codes 92571, 92572, and 92576 are performed together, they should be reported as CPT codes 92620 and 92621.
CPT codes 92551, 92559, 92560, and 92596 are not covered. CPT codes 92590, 92591, 92592, 92593, 92594 and 92595, are hearing aid evaluations and therefore not a Medicare benefit.
CPT codes 92587 and 92588 (Otoacoustic emissions or OAEs) are two special test methods that are used usually with very young infants, but may occasionally be used in adults as well. For this test, a tiny microphone is placed in the ear canal, and responses are analyzed to determine hearing capacity. After six months of age, infants, toddlers and older children may be tested with game-like activities such as Visual Reinforcement Audiometry (VRA)(CPT code 92579). For these, a child's responses to sounds are observed; an older child may press a button or raise a hand in response to sounds.
CPT code 92547 is an add-on code and should be reported in addition to the code(s) for the primary procedure(s) for each vestibular test performed (92541-92546).
When performing audiologic testing (CPT codes
92550, 92552, 92553, 92557, 92567, 92568, 92569,
92570) to monitor function in patients on continuing (current) long-term use (more than 14 days) of antibiotics known to be ototoxic, use ICD-9-CM code V58.62 (Long term (current) use of antibiotics).
CPT codes 92626 and 92627 have been added at the end of the comment period at the request of several commenters and are not restricted by the list of ICD-9-CM codes that support medical necessity.
The name of the physician ordering the testing is reported on the audiologist's claim. (For example, if a beneficiary undergoes diagnostic testing performed by an audiologist without a physician's referral, then these tests are not covered, even if the audiologist discovers a pathologic condition.) The entity billing for the audiologist's services may accept assignment under the usual procedure or, if not accepting assignment, may charge the patient and submit a non-assigned claim on their behalf.
For claims submitted to the carrier or Part B MAC: All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.
Claims for Audiologic and Vestibular Function testing services are payable under Medicare Part B in the following places of service:
CPT codes
92540, 92541, 92542, 92543, 92544, 92545, 92546, 92585, 92587, and 92588 have both professional and technical components. Modifiers -26 and -TC can be used to bill for just the professional or technical component of the service.
CPT codes 92547, 92552, 92553, 92555, 92556, 92561, 92562, 92563, 92564, 92565, 92571, 92572, 92575, 92576, 92577, 92582, 92583, 92584, 92586, 92620, 92621 and 92625 are technical component only codes. Modifiers -26 and -TC cannot be used.
CPT codes
92550, 92557, 92567, 92568, 92569,
92570 and 92579 are full service only (professional service codes) and modifiers 26 and TC are not valid.
CPT code 92585 (Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive) done in a hospital setting will be reimbursed as professional component only (modifier -26).
CPT codes
92540, 92541, 92542, 92543, 92544, 92545, 92546, 92585, 92587 and 92588 (professional component only), are payable when done in places of service: school (03), homeless shelter (04), office (11), home (12), assisted living facility (13), group home (14), temporary lodging (16), inpatient hospital (21), outpatient hospital (22), emergency room (23), skilled nursing facility (31), nursing facility (32), independent clinic (49), comprehensive inpatient rehabilitation facility (61), comprehensive outpatient rehabilitation facility (62), state or local public health clinic (71), and community hearing and speech centers (99).
CPT codes
92540, 92541, 92542, 92543, 92544, 92545 92546, 92585, 92587 and 92588 (technical and global components), are payable when done in places of service: school (03), homeless shelter (04), office (11), skilled nursing home (31), nursing facility (32), independent clinic (49), state or local health clinic (71) and community hearing and speech centers (99).
CPT codes 92547, 92552, 92553, 92555, 92556, 92561, 92562, 92563, 92564, 92565, 92571, 92572, 92575, 92576, 92577, 92582, 92583, 92584, 92586, 92620, 92621 and 92625 are technical service codes only and are payable in places of service: school (03), homeless shelter (04), office (11), assisted living facility (13), skilled nursing home (31), nursing facility (32), independent clinic (49), federally qualified health center (50), state or local health clinic (71), rural health clinic (72) and community hearing and speech centers (99).
CPT codes
92550, 92557, 92567, 92568, 92569,
92570 and 92579 (full service only (professional service codes) are payable when done in places of service: school (03), homeless shelter (04), office (11), home (12), assisted living facility (13), group home (14), temporary lodging (16), inpatient hospital (21), outpatient hospital (22), emergency room (23), skilled nursing facility (31), nursing facility (32), independent clinic (49), comprehensive inpatient rehabilitation facility (61), comprehensive outpatient rehabilitation facility (62), state or local public health clinic (71) and community hearing and speech centers (99).
CPT codes 92626 and 92627 (full service only (professional service codes)) are payable when done in places of service: office (11), home (12), temporary lodging (16), urgent care facility (20), skilled nursing facility (31), nursing facility (32), custodial care facility (33) and independent clinic (49).
Services by an independent audiologist to beneficiaries in a Part B SNF stay (beneficiaries who have exhausted their Part A covered SNF stay), are payable under Part B. These services should be billed directly to the Part B carrier by the provider of service.
For claims submitted to the fiscal intermediary or Part A MAC: Hospital Inpatient Claims: - The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB-04. The principal diagnosis is the condition established after study to be chiefly responsible for this admission.
- The hospital enters ICD-9-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67.
- For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 25, Section 75 for additional instructions.)
Hospital Outpatient Claims: - The hospital should report the full ICD-9-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67. If no definitive diagnosis is made during the outpatient evaluation, the patient's symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the provider should report an ICD-9-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (V70-V82).
- The hospital enters the full ICD-9-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67.
Additional Information:
These supplemental instructions apply within states outside the primary geographic jurisdiction with facilities that have nominated National Government Services to process their claims.
History:
Article published January 2010: based on the annual HCPCs update, CPT codes 92540 and 92550 have been added and CPT code 92569 has been deleted and replaced with CPT code 92570 effective for dates of service on or after 01/01/2010. Minoro changes were made to reflect current template language. Article published October 2009: The following coding guideline was revised: Audiological diagnostic tests may not be billed "incident to" the services of a physician or nonphysician practitioner. The following coding guideline was added: CPT codes 92626 and 92627 (full service only (professional service codes)) are payable when done in places of service: office (11), home (12), temporary lodging (16), urgent care facility (20), skilled nursing facility (31), nursing facility (32), custodial care facility (33) and independent clinic (49). Minor changes were made to reflect current template language.
06/05/2009 - In accordance with Section 911 of the Medicare Modernization Act of 2003, fiscal intermediary number 00270 was removed from this article as the claims processing for New Hampshire and Vermont was transitioned to NHIC, the Part A/Part B MAC contractor in these states.
05/15/2009 - In accordance with Section 911 of the Medicare Modernization Act of 2003, fiscal intermediary numbers 00180 and 00181 were removed from this Article as the claims processing for Maine and Massachusetts was transitioned to NHIC, the Part A/Part B MAC contractor in these states.
Article published March 2009: Source of revision - External. POS 13 "assisted living facility" has been added to the section
"For claims submitted to the carrier or Part B MAC" in paragraph 7, due to a provider request. Minor changes were made to reflect current template language.
Article published November 2008
11/15/2009 - The description for CPT/HCPCS code 92543 was changed in group 1
11/15/2009 - The description for CPT/HCPCS code 92568 was changed in group 1
11/15/2009 - CPT/HCPCS code 92569 was deleted from group 1
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