LCD for Audiologic/Vestibular Function Tests (L685)

 

Contractor Information

Contractor Name  National Government Services, Inc.   Contractor Number  00308  Contractor Type  FI

LCD Information

LCD ID Number  L685    LCD Title  Audiologic/Vestibular Function Tests    Contractor's Determination Number      AMA CPT / ADA CDT Copyright Statement  CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.     CMS National Coverage Policy  Title XVIII of the Social Security Act, Section 1862 (a)(7). This section excludes routine physical examinations. Title XVIII of the Social Security Act, Section 1862 (a)(1)(A). This section allows coverage and payment for only those services considered medically reasonable and necessary. Title XVIII of the Social Security Act, Section 1833 (e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim. CMS Manual, Publication 100-3, Chapter 15, sections 80.3 and 80.3.1. These sections refer to Otologic Evaluations and the definition of qualified Audiologists.  CMS Manual, Publication 100-4, Chapter 5. This chapter refers to Part B Outpatient Rehabilitation and CORF services.  CMS Manual, Publication 100-4, Chapter 7, section 40.1. This section refers to SNF Part B billing, Audiologic Function Tests.  Change Request (CR) 5142, dated June 23, 2006. Medicare Contractor Annual Update of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Change Request (CR) 5244, dated September 1, 2006. October 2006 Outpatient Prospective Payment System (OPPS) Outpatient Code Editor (OCE) Specifications Version 7.3 Change Request (CR) 5256, dated September 18, 2006. October 2006 Non-Outpatient Prospective Payment System Outpatient Code Editor (Non-OPPS OCE) Specifications Version 22.0. Change Request (CR) 5306, dated October 6, 2006. 2007 Healthcare Common Procedure Coding System (HCPCS) Annual Update. Change Request (CR) 5643, dated June 15, 2007. Medicare Contractor Annual Update of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)   Primary Geographic Jurisdiction  Connecticut Delaware New York - Entire State     Secondary Geographic Jurisdiction      Oversight Region  Region II       Original Determination Effective Date  For services performed on or after 06/01/2000     Original Determination Ending Date      Revision Effective Date  For services performed on or after 12/01/2007     Revision Ending Date      Indications and Limitations of Coverage and/or Medical Necessity  Indications: Vestibular function tests and/or diagnostic audiometric tests are covered when testing is for the purpose of determining the appropriate medical or surgical treatment for disorders of the auditory, balance and other neural systems.   For conductive hearing loss, hearing should be retested after medical or surgical treatment or observation for resolution of a medical problem. For sensorineural hearing loss, the audiologist or physician will determine when reasonable and necessary follow up testing should be done. However, billing for any testing assumes that the provider has a reasonable expectation that the patient will require medical or surgical treatment. Repeat testing for expected age related hearing loss; either as follow-up or to screen for hearing aids, is not covered.  Audiologic testing (CPT codes 92553, 92557, 92568 and 92569) may be performed for patients on continuing (current) long-term (more than 14 days) use of antibiotics known to be ototoxic, such as streptomycin and aminoglycosides. Conditioning play audiometry (CPA) and select picture audiometry (SPA) are usually performed to test hearing impairment in children 2 - 4 years of age or in mentally challenged patients. In CPA, the patient is asked to put an object in a specific place, ex.: a coin in a piggy bank when a specific sound is heard. SPA involves the use of pictures on cards and the patient's ability to correctly identify objects based on audiologic direction. When CPA or SPA are performed in mentally challenged patients, it is expected that the patient be able to follow the necessary simple commands to complete these tests. This policy will only allow coverage of these tests if the patients have signs or symptoms of hearing loss which must be documented in the medical records. Limitations: Hearing evaluations to monitor for symptoms of hearing loss when there is no patient complaint of hearing loss is considered screening and not covered (ex.: a patient with Chronic Meniere's Disease who is being treated with medication and monitored for symptoms of hearing loss but has no complaint of hearing loss). Audiologic testing is not covered when: The testing has not been ordered by a physician (even if a pathologic condition is discovered). Examples: The testing is ordered by a Skilled Nursing Facility (SNF) The testing is ordered by an agency The patient is self-referred The medical factors required to determine the appropriate medical or surgical treatment are already known by the physician or, are not under consideration and the diagnostic services are performed only to determine the need for or the appropriate type of hearing aid. Examples: The patient has already had audiologic testing that indicated that the patient needs a hearing aid. The patient is s/p stroke and complaining of hearing loss (a neurological examination would be indicated, not an audiologic examination). The patient has been diagnosed as having a tumor of the auditory system. The testing is a routine screening. Examples: The examination is required for third parties such as insurance companies, business establishments or government agencies. The routine screening is required by a facility or by the state. The patient has had audiologic testing in the past, has no new complaints and is referred for audiologic testing "to see if there is any change". The evaluation and service is related to hearing aids. Example: The patient is requesting a different type of hearing aid. The hearing loss was solely attributed to cerumen impaction. A diagnosis of cerumen impaction should be made by the physician, and the condition should be resolved prior to the patient being referred for audiologic testing.   Coverage Topic  Diagnostic Tests and X-Rays

Coding Information

Bill Type Codes:  Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. 12x Hospital-inpatient or home health visits (Part B only) 13x Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00) 22x SNF-inpatient or home health visits (Part B only) 23x SNF-outpatient (HHA-A also) 74x Clinic-ORF only (eff 4/97); ORF and CMHC (10/91 - 3/97) 75x Clinic-CORF 85x Special facility or ASC surgery-rural primary care hospital (eff 10/94)   Revenue Codes:  Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes. 042X Physical therapy-general classification 043X Occupational therapy-general classification 044X Speech language pathology-general classification 047X Audiology-general classification   CPT/HCPCS Codes  The following CPT/HCPCS codes can be billed using Revenue code 471 only: 92541 SPONTANEOUS NYSTAGMUS TEST, INCLUDING GAZE AND FIXATION NYSTAGMUS, WITH RECORDING 92542 POSITIONAL NYSTAGMUS TEST, MINIMUM OF 4 POSITIONS, WITH RECORDING 92543 CALORIC VESTIBULAR TEST, EACH IRRIGATION (BINAURAL, BITHERMAL STIMULATION CONSTITUTES FOUR TESTS), WITH RECORDING 92544 OPTOKINETIC NYSTAGMUS TEST, BIDIRECTIONAL, FOVEAL OR PERIPHERAL STIMULATION, WITH RECORDING 92545 OSCILLATING TRACKING TEST, WITH RECORDING 92546 SINUSOIDAL VERTICAL AXIS ROTATIONAL TESTING 92547 USE OF VERTICAL ELECTRODES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 92548 COMPUTERIZED DYNAMIC POSTUROGRAPHY NOTE: CPT code 92573 was deleted December 31, 2006. Effective for services performed on or after January 1, 2007, use CPT code 92700 to report a Lombard Test. The following CPT/HCPCS codes can be billed using Revenue codes 470 or 471: 92552 PURE TONE AUDIOMETRY (THRESHOLD); AIR ONLY 92553 PURE TONE AUDIOMETRY (THRESHOLD); AIR AND BONE 92555 SPEECH AUDIOMETRY THRESHOLD; 92556 SPEECH AUDIOMETRY THRESHOLD; WITH SPEECH RECOGNITION 92557 COMPREHENSIVE AUDIOMETRY THRESHOLD EVALUATION AND SPEECH RECOGNITION (92553 AND 92556 COMBINED) 92561 BEKESY AUDIOMETRY; DIAGNOSTIC 92562 LOUDNESS BALANCE TEST, ALTERNATE BINAURAL OR MONAURAL 92563 TONE DECAY TEST 92564 SHORT INCREMENT SENSITIVITY INDEX (SISI) 92565 STENGER TEST, PURE TONE 92567 TYMPANOMETRY (IMPEDANCE TESTING) 92568 ACOUSTIC REFLEX TESTING; THRESHOLD 92569 ACOUSTIC REFLEX TESTING; DECAY 92571 FILTERED SPEECH TEST 92572 STAGGERED SPONDAIC WORD TEST 92575 SENSORINEURAL ACUITY LEVEL TEST 92576 SYNTHETIC SENTENCE IDENTIFICATION TEST 92577 STENGER TEST, SPEECH 92579 VISUAL REINFORCEMENT AUDIOMETRY (VRA) 92582 CONDITIONING PLAY AUDIOMETRY 92583 SELECT PICTURE AUDIOMETRY 92584 ELECTROCOCHLEOGRAPHY 92700 UNLISTED OTORHINOLARYNGOLOGICAL SERVICE OR PROCEDURE The following CPT/HCPCS code can be billed using Revenue codes 471 only: 92585 AUDITORY EVOKED POTENTIALS FOR EVOKED RESPONSE AUDIOMETRY AND/OR TESTING OF THE CENTRAL NERVOUS SYSTEM; COMPREHENSIVE See "Coding Guidelines" section of the article for instructions on use of these codes The following CPT/HCPCS codes can be billed using Revenue codes 470 or 471: 92586 AUDITORY EVOKED POTENTIALS FOR EVOKED RESPONSE AUDIOMETRY AND/OR TESTING OF THE CENTRAL NERVOUS SYSTEM; LIMITED 92587 EVOKED OTOACOUSTIC EMISSIONS; LIMITED (SINGLE STIMULUS LEVEL, EITHER TRANSIENT OR DISTORTION PRODUCTS) 92588 EVOKED OTOACOUSTIC EMISSIONS; COMPREHENSIVE OR DIAGNOSTIC EVALUATION (COMPARISON OF TRANSIENT AND/OR DISTORTION PRODUCT OTOACOUSTIC EMISSIONS AT MULTIPLE LEVELS AND FREQUENCIES) 92597 EVALUATION FOR USE AND/OR FITTING OF VOICE PROSTHETIC DEVICE TO SUPPLEMENT ORAL SPEECH 92620 EVALUATION OF CENTRAL AUDITORY FUNCTION, WITH REPORT; INITIAL 60 MINUTES 92621 EVALUATION OF CENTRAL AUDITORY FUNCTION, WITH REPORT; EACH ADDITIONAL 15 MINUTES 92625 ASSESSMENT OF TINNITUS (INCLUDES PITCH, LOUDNESS MATCHING, AND MASKING) Non-covered tests include the following: 92551 SCREENING TEST, PURE TONE, AIR ONLY 92559 AUDIOMETRIC TESTING OF GROUPS 92560 BEKESY AUDIOMETRY; SCREENING 92590 HEARING AID EXAMINATION AND SELECTION; MONAURAL 92591 HEARING AID EXAMINATION AND SELECTION; BINAURAL 92592 HEARING AID CHECK; MONAURAL 92593 HEARING AID CHECK; BINAURAL 92594 ELECTROACOUSTIC EVALUATION FOR HEARING AID; MONAURAL 92595 ELECTROACOUSTIC EVALUATION FOR HEARING AID; BINAURAL 92596 EAR PROTECTOR ATTENUATION MEASUREMENTS   ICD-9 Codes that Support Medical Necessity  The following ICD-9-CM codes are eligible for the CPT codes 92541, 92542, 92543, 92544, 92545, 92546, 92547 and 92548. 386.00 - 386.04 MENIERE'S DISEASE UNSPECIFIED - INACTIVE MENIERE'S DISEASE 386.10 - 386.12 PERIPHERAL VERTIGO UNSPECIFIED - VESTIBULAR NEURONITIS 386.19 OTHER PERIPHERAL VERTIGO 386.2 VERTIGO OF CENTRAL ORIGIN 386.30 - 386.35 LABYRINTHITIS UNSPECIFIED - VIRAL LABYRINTHITIS 386.40 - 386.43 LABYRINTHINE FISTULA UNSPECIFIED - SEMICIRCULAR CANAL FISTULA 386.48 LABYRINTHINE FISTULA OF COMBINED SITES 386.50 - 386.56 LABYRINTHINE DYSFUNCTION UNSPECIFIED - LOSS OF LABYRINTHINE REACTIVITY BILATERAL 386.58 OTHER FORMS AND COMBINATIONS OF LABYRINTHINE DYSFUNCTION 386.8 OTHER DISORDERS OF LABYRINTH 386.9 UNSPECIFIED VERTIGINOUS SYNDROMES AND LABYRINTHINE DISORDERS 389.05 CONDUCTIVE HEARING LOSS, UNILATERAL 389.06 CONDUCTIVE HEARING LOSS, BILATERAL 389.10 SENSORINEURAL HEARING LOSS UNSPECIFIED 389.11 SENSORY HEARING LOSS, BILATERAL 389.12 NEURAL HEARING LOSS, BILATERAL 389.13 NEURAL HEARING LOSS, UNILATERAL 389.14 CENTRAL HEARING LOSS 389.15* SENSORINEURAL HEARING LOSS, UNILATERAL 389.16* SENSORINEURAL HEARING LOSS, ASYMMETRICAL 389.17 SENSORY HEARING LOSS, UNILATERAL 389.18 SENSORINEURAL HEARING LOSS, BILATERAL 389.20 MIXED HEARING LOSS, UNSPECIFIED 389.21 MIXED HEARING LOSS, UNILATERAL 389.22 MIXED HEARING LOSS, BILATERAL * Tests for the ICD-9-CM codes indicated with an asterisk (*) are covered only for an INITIAL evaluation of a hearing problem and for subsequent evaluation when the medical necessity is clearly documented in the patient's medical record. The following ICD-9-CM codes are eligible for CPT codes 92552, 92553, 92555, 92556, 92557, 92567, 92568 and 92569. 225.1 BENIGN NEOPLASM OF CRANIAL NERVES 300.11 CONVERSION DISORDER 381.00 - 381.06 ACUTE NONSUPPURATIVE OTITIS MEDIA UNSPECIFIED - ACUTE ALLERGIC SANGUINOUS OTITIS MEDIA 381.10 CHRONIC SEROUS OTITIS MEDIA SIMPLE OR UNSPECIFIED 381.19 OTHER CHRONIC SEROUS OTITIS MEDIA 381.20 CHRONIC MUCOID OTITIS MEDIA SIMPLE OR UNSPECIFIED 381.29 OTHER CHRONIC MUCOID OTITIS MEDIA 381.3 OTHER AND UNSPECIFIED CHRONIC NONSUPPURATIVE OTITIS MEDIA 381.4 NONSUPPURATIVE OTITIS MEDIA NOT SPECIFIED AS ACUTE OR CHRONIC 381.50 - 381.52 EUSTACHIAN SALPINGITIS UNSPECIFIED - CHRONIC EUSTACHIAN SALPINGITIS 381.60 - 381.63 OBSTRUCTION OF EUSTACHIAN TUBE UNSPECIFIED - EXTRINSIC CARTILAGENOUS OBSTRUCTION OF EUSTACHIAN TUBE 381.7 PATULOUS EUSTACHIAN TUBE 381.81 DYSFUNCTION OF EUSTACHIAN TUBE 381.89 OTHER DISORDERS OF EUSTACHIAN TUBE 381.9 UNSPECIFIED EUSTACHIAN TUBE DISORDER 382.00 - 382.02 ACUTE SUPPURATIVE OTITIS MEDIA WITHOUT SPONTANEOUS RUPTURE OF EARDRUM - ACUTE SUPPURATIVE OTITIS MEDIA IN DISEASES CLASSIFIED ELSEWHERE 382.1 - 382.4 CHRONIC TUBOTYMPANIC SUPPURATIVE OTITIS MEDIA - UNSPECIFIED SUPPURATIVE OTITIS MEDIA 382.9 UNSPECIFIED OTITIS MEDIA 384.20 - 384.25 PERFORATION OF TYMPANIC MEMBRANE UNSPECIFIED - TOTAL PERFORATION OF TYMPANIC MEMBRANE 385.00 - 385.03 TYMPANOSCLEROSIS UNSPECIFIED AS TO INVOLVEMENT - TYMPANOSCLEROSIS INVOLVING TYMPANIC MEMBRANE EAR OSSICLES AND MIDDLE EAR 385.09 TYMPANOSCLEROSIS INVOLVING OTHER COMBINATION OF STRUCTURES 385.10 - 385.13 ADHESIVE MIDDLE EAR DISEASE UNSPECIFIED AS TO INVOLVEMENT - ADHESIONS OF DRUM HEAD TO PROMONTORIUM 385.19 OTHER MIDDLE EAR ADHESIONS AND COMBINATIONS 385.22 IMPAIRED MOBILITY OF OTHER EAR OSSICLES 385.23 DISCONTINUITY OR DISLOCATION OF EAR OSSICLES 385.30 - 385.33 CHOLESTEATOMA UNSPECIFIED - CHOLESTEATOMA OF MIDDLE EAR AND MASTOID 385.35 DIFFUSE CHOLESTEATOSIS OF MIDDLE EAR AND MASTOID 386.00 - 386.04 MENIERE'S DISEASE UNSPECIFIED - INACTIVE MENIERE'S DISEASE 386.10 - 386.12 PERIPHERAL VERTIGO UNSPECIFIED - VESTIBULAR NEURONITIS 386.19 OTHER PERIPHERAL VERTIGO 386.2 VERTIGO OF CENTRAL ORIGIN 386.30 - 386.35 LABYRINTHITIS UNSPECIFIED - VIRAL LABYRINTHITIS 386.40 - 386.43 LABYRINTHINE FISTULA UNSPECIFIED - SEMICIRCULAR CANAL FISTULA 386.48 LABYRINTHINE FISTULA OF COMBINED SITES 386.50 - 386.56 LABYRINTHINE DYSFUNCTION UNSPECIFIED - LOSS OF LABYRINTHINE REACTIVITY BILATERAL 386.58 OTHER FORMS AND COMBINATIONS OF LABYRINTHINE DYSFUNCTION 386.8 OTHER DISORDERS OF LABYRINTH 386.9 UNSPECIFIED VERTIGINOUS SYNDROMES AND LABYRINTHINE DISORDERS 387.1 OTOSCLEROSIS INVOLVING OVAL WINDOW OBLITERATIVE 388.2* SUDDEN HEARING LOSS UNSPECIFIED 388.30 - 388.32 TINNITUS UNSPECIFIED - OBJECTIVE TINNITUS 388.40 ABNORMAL AUDITORY PERCEPTION UNSPECIFIED 389.00 CONDUCTIVE HEARING LOSS UNSPECIFIED 389.02 CONDUCTIVE HEARING LOSS TYMPANIC MEMBRANE 389.03 CONDUCTIVE HEARING LOSS MIDDLE EAR 389.04 CONDUCTIVE HEARING LOSS INNER EAR 389.05 CONDUCTIVE HEARING LOSS, UNILATERAL 389.06 CONDUCTIVE HEARING LOSS, BILATERAL 389.08 CONDUCTIVE HEARING LOSS OF COMBINED TYPES 389.10* SENSORINEURAL HEARING LOSS UNSPECIFIED 389.11* SENSORY HEARING LOSS, BILATERAL 389.12* NEURAL HEARING LOSS, BILATERAL 389.13 NEURAL HEARING LOSS, UNILATERAL 389.14* CENTRAL HEARING LOSS 389.15* SENSORINEURAL HEARING LOSS, UNILATERAL 389.16* SENSORINEURAL HEARING LOSS, ASYMMETRICAL 389.17 SENSORY HEARING LOSS, UNILATERAL 389.18* SENSORINEURAL HEARING LOSS, BILATERAL 389.20 MIXED HEARING LOSS, UNSPECIFIED 389.21 MIXED HEARING LOSS, UNILATERAL 389.22 MIXED HEARING LOSS, BILATERAL