Some questions tend to plague clinicians in their endeavor to execute appropriate coding and billing practices. To resolve some of these issues, I offer this "Fireside Chat" to address the following issues:
- How many codes can I bill for the same procedure?
- What kind of documentation is necessary?
- How do I know which code to bill?
- What happens if I am doing a procedure for which there is no code and I want to get paid?
- How many units of balance evaluation codes can be billed for the same date of service?
- My billing office is doing all of my coding for me - is that okay?
- What is the difference between "screening" and "diagnostics" for otoacoustic emissions?
1- How many codes can I bill for the same procedure?
It is allowable to bill only one code for each procedure. Each CPT code is highly specific with regard to the procedure it describes, including well-defined boundaries as to when the procedure begins and when it ends. All details of what transpires within a described procedure are contained within the CPT "descriptor." There are many instances when facilities have developed their own descriptors for respective CPT codes. At times, these descriptors do not match what is written in the CPT manual. It is important that descriptors in the CPT manual are always the same as descriptors found on an encounter form or patient voucher.
I am aware of occasions when audiologists have billed two codes for vestibular rehabilitation: therapeutic exercises and neuromuscular re-education. If these codes are billed and only one clinical activity was performed, then improper coding and billing occurred. Only one code should describe what took place for each procedure.
2- What kind of documentation is necessary?
The answer depends in part on who is responsible for billing. If the physician is responsible for the billing, and the service is performed as "incident to," then there are occasions when a note on the bottom of the audiogram, or a brief note in the patient's medical chart may be appropriate. However, if the audiologist is responsible for billing, documentation must be more extensive. The fundamental elements of documentation must include; the reason the patient was seen, the motivation for the specific procedures performed, observations and clinical findings, interpretation of those findings, recommendations, date and original signature. Taken together these elements comprise a formal report. Depending upon the site of service, the location of the patient's medical record and any "payer" requirements, the documentation may be in the form of a detailed note in the progress notes section of the medical record or a separate, formal report.
The specific sections of the report must include; the history (patient complaints or concerns, symptoms, relevant family history, relevant medications, relevant personal history, and specific reason for referral), observations and clinical findings (specific procedures performed, noteworthy patient responses or reactions, results or outcomes, and statement of validity of test results if appropriate), assessment (your interpretation of the findings and your conclusions), recommendations and referrals, signature and date. The documentation must be sufficient that someone who is unfamiliar with the patient may read your notes and understand with clarity why you saw the patient, what you did, what you found, and why you offered the specific recommendations. This documentation must be in agreement with, and supportive of, the CPT code and the ICD-9 diagnosis code chosen for billing.
3- How do I know which code to bill?
The decision as to which code to bill is determined by what was done and the specific code descriptors within the AMA's CPT manual. Every clinician certainly should possess a current CPT manual which describes all procedure codes within the scope of practice of their specific discipline. It is not appropriate to rely on "coders" to make the final decision regarding code choice nor is it appropriate to depend on facility billing offices to develop code descriptors that are unique to that facility. Please note, in the event of an audit, the licensed professional holds complete responsibility for ensuring appropriate code selection and appropriate billing practices. Professional coders hold primary responsibility of double checking to make sure that the appropriate code was selected and that the encounter or voucher form is "clean" to facilitate and expedite payment. However, it is not their responsibility to ensure accuracy of the code descriptor, especially if the facility edited or otherwise modified the descriptor to meet local needs. The final authority for the description of every procedure rests within the AMA CPT Editorial Panel and its annual publication -- the CPT Manual. Copies of the CPT manual may be purchased from the AMA at www.AMA-Assn.org.
4- What happens if I am doing a procedure for which there is no code, and I want to get paid?
In this situation, the clinician has two options. The first option is to bill 92700 (unlisted otorhinolaryngological service or procedure) and submit the voucher to the third party payer with a detailed report describing why you chose that particular procedure, what specifically was done, how long it took, your findings and conclusions, and your recommendations. The reason for submitting a detailed report is to justify your selection of the procedure for that patient and also to justify the charges you are billing.
A second option is to have the patient sign an Advanced Beneficiary Notice (ABN) to let them know that this procedure may not be covered by their insurance in which case they would be responsible for payment. If the procedure is justifiable on the basis of its diagnostic value, and not for the convenience of the clinician, and it does not have its own CPT code, then a standard practice of offering an ABN to the patient prior to the procedure may be worthwhile.
Be aware that an ABN must be completed before the patient leaves the waiting room to enter the test area. If the patient is sitting in the test area or has already had the procedure done, an ABN must not be completed and the patient is not necessarily liable for charges rendered as a result of the unlisted code procedure.
5- How many units of balance evaluation codes can be billed for the same date of service?
All evaluation codes for audiology are considered to be "contact codes". This means only one unit of each code can be billed for the service rendered. However, as most audiologists are familiar, there is one exception.... CPT code 92543. That particular code, representing electronystagmography (ENG) caloric testing, is correctly billed "per irrigation," to a maximum of four irrigations.
The guideline of billing one unit (or once) per date of service is particularly relevant to CPT code 92546 (sinusoidal vertical axis rotational testing). Regardless of the number of frequencies assessed or other procedures performed as part of the protocol, there is no allowance to bill this code more than once per date of service. The reason for this restriction focuses on the valuation process for the procedure. For audiology codes, the valuation is based on the typical time to complete all elements of a protocol, the capital expense associated with the equipment, and disposable supplies. Each time the code has been presented for re-valuation a survey has been completed to estimate the range of times the clinicians need for "typical" patients. The median value is most often selected with the realization that some patients may take less time and other patients may take more time. But the contact codes are just as the term implies, codes that are billed once each time the audiologist makes face-to-face contact with the patient.
Again, with the exception of CPT code 92543, multiple billings with regard to number of units for each balance evaluation code is not appropriate.
6- My billing office is doing all of my coding for me - is that okay?
That is not necessarily a good or bad thing, as long as the audiologist realizes that he or she is ultimately responsible for ensuring appropriate coding and billing. It is always the licensed professional provider who maintains this responsibility. Responsibility for correct coding does not rest with the facility, the billing office, or the professional coder. Should an audit occur, the auditors will come to the licensee and not to the administrative personnel.
This (above) is why it is extremely important that the documentation be complete, of sufficient detail, and in agreement with the codes selected for billing.
7- What is the difference between "screening" and "diagnostics" as it applies to OAEs?
For pure tone testing, the difference between screenings and diagnostic tests are somewhat self-explanatory. The question regarding screenings verus diagnostics is much more difficult as it relates to oto-acoustic emission testing.
Some professionals have advocated that for distortion product otoacoustic emissions (DPOAEs) the use of four frequencies comprises a screening procedure, whereas six frequencies justifies use of the diagnostic OAE CPT code (92588). This advocacy is in error. The valuation of a screening distortion product otoacoustic emissions test is on the basis of a finite number of frequencies (i.e., four or six) whereas the valuation of any diagnostic DPOAE test is on the basis of cochlear mapping using multiple frequencies per octave across numerous octaves. An example of cochlear mapping might entail the use of four or five frequencies per octave beginning at 500 hertz and continuing through 8000 hertz. The valuation of a screening OAE is on the basis of approximately eight minutes total for the procedure whereas a diagnostic OAE is valued on the basis of approximately 30 minutes for the total procedure.
For transient emissions, the difference between screening and diagnostic focuses on the number of intensities evaluated.
In summary, it is important to know (in significant detail) the descriptor of each CPT code as found in the AMA manual. It is also important to ensure that the documentation supports the codes selected. Unless the code specifies multiple units or is time coded, an audiologist may bill only one unit of each code per date of service.
-------------
Robert C. Fifer, Ph.D. is the Director of Audiology and Speech-Language Pathology at the Mailman Center for Child Development, Department of Pediatrics, University of Miami School of Medicine. He is a member of ASHA's Health Care Economics Committee and the ASHA representative to the American Medical Association's Health Care Professions Advisory Committee for the Relative Value Utilization Committee in addition to being ASHA's representative to the AMA's Practice Expense Advisory Committee.
