Can you give an overview of CPT Codes, ICD9 Codes and the basics of documentation?
This is a very common question and so let me provide a general overview.
CPT Codes
It's important to remember that the CPT codes were created for and are owned by physicians. They are copyrighted by the American Medical Association (www.ama-assn.org/), and all use of CPT codes comes through the authority and auspices of the AMA. They've been around since the mid-1960s and serve as the primary purpose of standardizing the language of what is done to and for a patient.
We (audiology) were a recent afterthought as far as the CPT system, and really since only around 2000-2001 have we been given a voice in the process and authority to influence the process. So we are a fairly recent entrant, but we do have a voice, and that's what's important.
CPT Modifiers
One of the key things about modifiers is that when you do something, and the basic protocol doesn't change but something changes around the circumstances under which you do it, there is a modifier to help to explain what the circumstances were.
Case in point: all of our codes are valued on the basis of two ears. And if you did tympanometry for both ears, you would bill 95267. If you did tympanometry, however, on just one ear, then there's a modifier, -52, to say that you did not change the basic protocol of the procedure but you did not do all that you typically do with the procedure, and so what you would report would be a 95267-52.
If you're doing the same thing, again, on the same date of service, such as with a glycerol or a urea test, for example, then a -76 could be a modifier that is entertained for repeating a procedure on the same date of service.
And then, if you do something that's unusually longt routinely long, but unusually longr a particular patient, then a -22 is extended procedure. And with that, you would have to submit a report to justify why you're billing a -22, how much extra time it took, what all you did, etcetera.
So, the CPT coding system, as well as the modifiers, are contained within the CPT manual. And if you don't have one, I highly recommend that you do purchase a CPT manual (catalog.ama-assn.org), and that you not just purchase one but you purchase one every year, simply because codes are deleted, new codes are added, and you need the authoritative book, in order to know how to code and what each code represents.
CPT is a system where you have to have an exact fit between what you did and the code that you choose. If it doesn't fit then you must not choose that code, and it goes under the unspecified otolaryngological procedure code, 92700.
ICD-9
In contrast, ICD-9 does not have that same level of specificity. The ICD-9 code list that we use had not been updated since 1971, until last year, which, for the first time, we had some new codes and some modifications of current codes placed into the book.
There are some additional new codes that will appear in the October 1st edition of the new ICD-9 manual;they have been approved. So we're just now starting to update all the coding diagnosis codes in ICD-9, for the first time in more than 30 years. And boy, has it been necessary.
But the moral of the story is that ICD-9 does not carry the precision as does CPT. With ICD-9, you have to choose a diagnosis code that will come as close as possible to the exact truth. And sometimes, you can't come to the exact truth, so you have to come as close as you can in order to be able to say, "This is what I found."
There are also some rules to selecting an ICD-9 code when things turn out to be normal, and we'll discuss that a little bit later on in the Q & A because some questions did pop up specific to that issue.
Documentation
Documentation is another area. When audiologists and, well, when anyone has been audited, whether it be physician, physical therapist, audiologist, SLP, it doesn't matter who, when anyone has been audited, the primary area where they have fallen down and become susceptible to penalty has been based upon the lack of appropriate documentation. And there are six elements to documentation that must be adhered to consistently.
- The first element is a history - Why is a person there? This must include the chief complaint, the presenting complaint, elements of the prior occupational or personal history, family history, enough background information to justify what you are about to do to the patient and for the patient. Without this information there really is no justification for why you saw the patient, and that documentation is absolutely essential to meet the requirement, the fundamental requirement of medical necessity.
- The second element is - What did you do? This is a description of all the diagnostic tests that we engaged in, and not just a description of the tests but also what we found. For example, "Hearing sensitivity was evaluated using standard audiometric techniques with supra-aural earphones. Pure-tone thresholds indicated a moderate to severe sloping sensorineural hearing loss in the right ear and a mild to moderate sensorineural hearing loss in the left ear." So you're describing what you're doing and also what you're finding at the same time in this particular section.
- The next element - What does it mean? This is your clinical interpretation. Sometimes it's a repeat of what you found. "These results are consistent with moderate to severe sensorineural hearing loss." Many times, though, you want to embellish that just a little bit to have a practical implication. In the case of unilateral hearing loss, for example, that may mean that the person needs a medical evaluation to ensure that there is no treatable active disease or medical issue involved with that unilateral hearing loss. The same can be for unilateral tinnitus, just use these two examples. So what's your interpretation of what you found?
Other times you may want to have some information in there regarding the practical functional limitations that the hearing loss will pose upon the individual. Physicians tend to be pretty smart when it comes to overall education, but they are not real smart when it comes to interpreting our results. They know what hearing loss means, but they don't always know what it means - if you know what I mean. Hearing loss - "yeah, you don't hear well." But what does it mean to that person's everyday function? Many times physicians really don't know that, and so it's up to us to explain it to them as appropriate to that instance, and this would be the section to do it. - Number four, based on the results, what do we recommend? The results have to be a logical flow from everything that happened before. What you recommend has to be supported by the history, by what you did, what you found, and also your clinical interpretation. It's a logical conclusion to everything that was written prior to that section in the report.
- Number five - You have to have an original signature. Do not, do not, do not use a name stamp or a facsimile signature. The one exception to that is if you are in a facility that uses electronic medical records. Then your signature is your login, and the working assumption there is that you, and only you, have access to that patient's medical record - and nobody but you. And by the way, there are some penalties involved should you share your access code with anyone else. And so by logging in under your name in an EMR, the computer does indeed assume that it is you.
- And number six - The date. The date must be the date of evaluation, the date the patient was seen.
Because if there is a mismatch between the date of service on the voucher that goes in for reimbursement, and the date of the evaluation on the report, if there's a mismatch between the two, you did not see that patient. That patient never came into your office, nothing ever happened, and you billed inappropriately.
So you must make sure that the date on the report is the date of the evaluation, and the date of service on the voucher that goes in for payment, is indeed the date that matches the date of the report.
Your recommendations now come under some specific guidelines, all under the heading of "Medical Necessity." Every one of us, me included, when we went through our professional training for audiology, were taught that when you find sensorineural hearing loss, you do an annual follow-up re-check to monitor the status of the hearing loss. That is no longer true under acceptable medical guidelines for medical necessity.
There are three broad areas, by which we are justified in recommending that the patient return to see us. One is if we can document that the patient has a dynamic condition. One illustration of a dynamic condition would be Endolymphatic Hydrops, in which case, you may have a change in hearing status that is unpredictable.
A perceived or a real change in status as reported by the patient, would be the second justification for the patient coming back to see you for a repeat visit—a repeat audiogram. Under that scenario you would tell the patient, "Now if you have a change in your status, or something new appears like ringing in the ears, or if you find that you're not hearing as well as what you are now, then I want to see you again to see what's going on."
Then you document that in that way in the chart, so that you fall under the heading of, "If the patient has a change in status, real or perceived, then a return visit should occur."
The third category is that if there's a risk of change in status due to a related diagnosis. I'm a pediatric audiologist, and one of the most common things that we encounter is the diagnosis of Cytomegalovirus (CMV). The child may have normal hearing sensitivity as predicted by ABR, and OAE, and VRA, and all of these other tests that we use in pediatric audiology. But, that related diagnosis of CMV places that child at great risk for a change in status. That would justify a return visit, again under the heading of "Medical Necessity." What is not acceptable any more is simply to tell the patient to come back for an annual re-check to see what's going on.
Now you can do make that recommendation, but if you do, it would not be appropriate to bill Medicare, Medicaid, or any other third-party payor because that is your desire as a provider, and not based upon a dynamic condition, or a risk of change, or anything else that would fall under the categories listed above.
"It's simply because I was taught that when you find Sensorineural Hearing Loss, you bring them back every year for a re-check." That's well and good, but that does not fall under the heading of "Medical Necessity" anymore.
Now let me digress just a second, and let you have some insight as to how this came about. When the cost of health care was much less than what it is now, we could make that recommendation and get away with it, simply because it was not a burden to the system.
But, again this comment is not just for audiology. It is for all of health care in general. The cost of healthcare has gone up so much that arbitrarily having the patient come back for repeat visits, when there's no risk of dynamic change or no risk of change due to related diagnosis, is no longer acceptable. It's simply that the healthcare system simply cannot afford it anymore. If there is a change, or if there's a documented risk for change, then you're justified.
If you do an evaluation, and there's a cautionary follow up, there must be a risk for change in status. An example here would be otitis media. One of the questions coming up later on is, "When I saw a child about four weeks ago, I documented a conductive hearing loss. The child has been under treatment, and is now coming back." That would qualify under medical necessity, because you are looking for a change, aka, improvement in status in that child. Hopefully you're going to find normal results at the end of this evaluation. Your documentation and your diagnosis code must reflect what you found on this follow-up visit.
Can you go over the most recent updates in CPT codes?
With regard to the updates for this year, a number of you participated in surveys to convert some of our CPT codes from practice expense to work RVUs. I do appreciate your efforts and your contribution very much in that effort. You need to know that we did present them. I cannot tell you what the outcome was because I don't know what the outcome was.
I know that we had a hard time because the American Academy of Otorlaryngology Leadership is very much opposed to our effort to convert our reimbursement formula from practice expense only to work RVUs. They came in with their own work survey that was much lower than ours. We were basically in a locked room for the better part of 8 hours trying to negotiate. We presented our positions to the AMA panel.
CMS now has the information, the Center for Medicare and Medicaid Services. We do not know if, number one, they will accept the work survey. Number two, we do not know what the assignment of the work RVU will be, because they have complete laterality to accept, reject, or modify what the AMA sends. We also don't know what the final value will be for the codes, probably not until the Physician Fee Schedule is released on November 1st.
We're not going to submit any more new codes for conversion until we see what transpired with these codes. For 92557 and 92579, in particular, we are told preliminarily by CMS that their draft run, their rough run on the calculation, the value should not change that much. But we don't know at this moment what that means. On some of the codes that we submitted, if CMS does accept them, and if everything holds true, we're hopeful that the value will increase substantially, in particular for some of the cochlear implant codes.
New codes have come out;again on those codes we really don't know what's going to happen, though, until November 1st. On the new codes coming out we have auditory brainstem implant programming. That will affect just a very small handful of you who work primarily in large neuro-otology centers.
The other code, the team conference code, will be appearing in the book next year. It has been surveyed, and that information has been turned in to CMS. We'll find out what they do with it. That will allow you to account for your time in a team conference with other individuals concerning a specific patient. That's something that we, and other professionals, don't have access to right now.
New codes in the pipeline will be a whole new balance family of codes. We're not going to delete the current balance diagnostic procedures, the 92541 through 92548. But we have to create a new family, in parallel, to account for the goggle recording of nystagmus and the associated protocols for analysis that come with that.
Canalith repositioning procedure, aka Epley. That'll be a proposal that's about ready to go. That'll be jointly presented by neurologists, ENTs, audiologists, and physical therapists, because all of those groups have vested interest in that procedure.
Cochlear implant diagnostics. This is a troubleshooting procedure for implants, and VEMP and the ASSR have now met all of the criteria for eligibility that AMA demands of a new code proposal. So we'll be preparing applications for that, for new codes.
What codes should we use for CRP, canalith repositioning procedure/Epley Maneuver?
The answer to this question is: it depends on who's paying. And for that, you'll need to check the website of the insurer, to see if they have any type of decision coverage on that.
Your Medicare carrier at your state level, usually that's a subsidiary of the Blues, typically has some documentation or a carrier decision on how to code for this. But the various options I have come across include 92700, which is the unspecified otolaryngologic procedure;97110, therapeutic exercises;97112, neuromuscular re-education;or 97530, therapeutic exercises. Which one you bill, again, depends upon the payer.
Now, one thing that you can do... Every insurance company has an office of provider education. And every insurance company, and HMO, has a provider liaison. What you can do is to call them.
You don't want to ask, "What code do you use for CRP or for Epley?" because they won't tell you. What you do ask is, "Can I report 97110 with this diagnosis?" and you fill in the blank for what diagnosis you want to use. And they will typically come back and say, "Yes, you can, " or "No, you can't." And so you give them the code and you find out if they will authorize payment for it.
But these are the four most common codes I've come across for Epley, and this simply highlights that we need that new code for the CRP, aka Epley.
What's the code for the Dix-Hallpike?
That is 92542, a positional nystagmus test, minimum of four positions, with recording. The reason why 92542 doesn't say "Dix-Hallpike" is because, when this code came into existence, the AMA had a rule, at that time, that said you could not use a proper name as part of the code descriptor. The descriptor had to describe the procedure itself, in which case you are putting the patient into various positions, looking for the onset of nystagmus.
How many times can 92547 be billed?
Up to seven times per date of service, IF--and you'll notice I have "if" in capital letters--number one, you used good old fashioned surface electrodes, two of them, above and below the eye, for a vertical channel. And you can bill it once per unit of service for 92541, 92542, one time for each of those. 92543 is billable up to four units, so that's four times. 92544, and also 92545, each of those is billable in one unit per date of service. However, you must know that there is a CCI edit to prohibits the reporting of 92541 with the other balance codes on the same date of service. You won't find this under "92541" on the CCI edit list, but you will see it when you look at the other balance codes.
So up to seven times is what you are allowed for 92547, but only if you use electrodes. If you use goggles to record nystagmus, you must not bill 92547, under any circumstance. That's the one compromise we came to with the AMA when they wanted to cut us off from that code completely.
So if you use goggles, don't bill 92547. If you use electrodes, that's fine. You can piggyback it onto each of the other codes that you use.
What is a conformity evaluation?
The answer to this was gleamed from a consensus of a variety of Medicaid websites for a number of states all throughout the country.
In essence, a conformity evaluation is a hearing aid check that is performed sometime after the hearing aid dispensing for the purpose of evaluating the performance of the hearing aid, evaluating the benefit that the hearing aid provides the patient, and to ensure that the hearing aid continues to meet the original prescription such that it's settings have not changed somewhere in the interim. You want to assure that it continues to do what you wanted it to do in the first place.
When is a referral from a PCP necessary?
Medicare is first and foremost. With Medicare, everything's done under medical necessity. It must be done under the active treatment of the primary care physician. When a patient comes in to see you, you must not test the patient until you have a referral from that primary care physician.
If you test the patient and then call the physician and say, "Hey, I just had Jane Razzlefratz in here. We found some sensorineural hearing loss. Can I get a referral from you so that we can bill Medicare?" Don't do that. That is not at all appropriate. You have to have the referral before you test Jane Razzlefratz, and it should be in writing, on a physician letterhead or a script pad. It can be faxed to you. It can be hand-carried by the patient. It can be mailed to you. But you need to have written documentation, in the event of an audit, so that you can assure the auditor that what was done, from your perspective, was under the guise of medical necessity, by referral of the primary care physician, or the primary treating physician, if you please. Sometimes a request comes from an ENT as opposed to the PCP. So it's got to be a physician referral.
Medicaid also requires a referral of a PCP, but may not be as strict as Medicare, depending upon what state you are in. For example, in Florida, someone who has regular Medicaid or MediPass is eligible to see an audiologist without first going to the physician.
But we are obligated to ensure that what we do falls under the heading of medical necessity, and we are also obligated to keep that physician in the loop as a primary, active, treating physician by providing a report to that physician for what we found and having physician approval for any follow-up recommendations.
HMOs obviously require referral for everything. In the beginning, HMOs were a way to reduce the cost of health care by providing quality care and preventative medicine. I'm not trying to be mean or facetious;just trying to be real. In most recent days, HMOs have moved to the area of [sighs] less service and rationed health care, and that way, will earn more money. That seems like that's become the motto of HMOs. Because of some of the backlash, some HMOs are loosening the referral requirements, but no one has a completely open door to see an HMO patient.
So they still require a referral of primary care for most everything that goes on. A hassle factor, gatekeeper situation.
Now, under this broad heading, I'm going to offer to you a recommendation of what we do here in my office. We started doing this several years ago, and it has proven to be very beneficial so that we're not caught by surprise by denial of payment, or at least not as much as we used to, and the patient's not caught by surprise by a denial of coverage.
And that is, for every patient that comes in--regardless of the status, regardless of the payer--someone here in the office calls the payer to ensure, number one, that the patient is still eligible under that payer, that the services that we provide are eligible for reimbursement under that payer, and that the person providing the services is eligible to file for reimbursement under that particular contract. Because if the answer is no to any of the above, we need to know that we are not participating providers and we're not eligible to reimburse so that we can weigh if we want to see the patient. Also, the patient also needs to know that the service may not be covered.
And that serves to eliminate any surprises, it's a pre-authorization or prior authorization process, if you please, for everyone who walks through the door. And that has really helped to cover us in cases where we've gotten prior authorization and, if we get a denial, we have a basis for appeal that's much stronger than if we have not gone through that exercise.
What happens when the insurance company will not tell you how much they will reimburse?
Again, the two magic offices are provider liaison and the provider education office. You do want to call them to find how much information they would give you:
Number one: If there is a measured benefit for example $500 maximum. Would that would go toward the hearing aid or $500 covers everything involved for the price of the hearing aid and the cost of your services? Is this a benefit that applies on a per hearing aid basis or would include binaural hearing aids? Is it a hearing aid for each ear every three years? These qualifications change a lot.
If they will not tell you at all, anything at all, about what you will be reimbursed, what eligibility, what restrictions there are, then what I suggest is to turn the patient loose on them because that patient can be his or her own advocate and really does carry a lot of weight in order to get things revealed.
If that provides no good fortune to you in learning what's appropriate and what's not, what's eligible and what's not, then you have some heavy decision making to do to decide if you really want to participate in this program.
I am aware of some plans where it is indeed better to let your competition down the street, take the loss than for you to take the loss where $500 is expected to cover the cost of a high end digital and your services and also all of your follow up services forevermore. There is a cost benefit risk factor there that sometimes just doesn't make sense for us get involved in.
Is V5010 the same as 92557 and can they be billed on the same date?
Yes and no and here's why: 92557 is contained within V5010. A V5010 is the audiogram as you would find for a 57, but V5010 goes further to include additional measures that are necessary for the assessment of a hearing aid selection. That would include MCL, UCL, loudness growth functions, anything like that that's necessary in order for you to make the determination, Number one: Is the patient a candidate? Number two: What restrictions am I facing in the selection of a hearing aid? Number three: What do I have to watch out for once I actually put a hearing aid on this individual?
So, they are similar but not quite the same in that V5010 is more expansive than 57, and no, they may not be billed on the same date of service simply because that would be double billing for the audiogram. V5010 by the way is used primarily by Medicaid whereas 92557 is also used by Medicaid but for a medical evaluation audiogram whereas V5010 is oriented specifically to the preparation for hearing aid selection.
Coding for normal hearing - can V65.5 be used?
No, V72.1 was used by many for a long time. That code no longer exists and has been replaced by V72.11 and V72.19. My guidance is do not use any V code for normal hearing and the reason why is because the V codes fall into a supplemental coding section of the ICD-9 manual and it's under section that documents things that were done some of which were not medically necessary and so the general understanding for the V codes is that they are indeed not medically necessary for what you just did to and for the patient. The V codes also represent procedures, not diagnoses.
Here's an illustration of what I mean, if I were to go and see my primary physician for let's say a follow up of a high blood pressure check to see if my blood pressure is responding to the medication and I say to you: "While I'm here, can you get my hearing checked?" And you say "Sure" and calls someone over to check my hearing. Well, that is a procedure that needs to be documented but it was not medically necessary in the sense that it was not related to the primary reason why I went to see the physician. That would be reported as V72.11 - other hearing test, plus there would be the documentation for that particular procedure. So, stay away from the V codes.
For those of you with paper and pencil, get ready. I have a document for you to look up on the CMS website. CMS once again is the Center for Medicare and Medicaid Services. The website is www.cms.hhs.gov. Once you are on the home page for Medicare and Medicaid Services, in the search box type in the following: Medicare bulletin AB-01-144, A-B-0-1-1-4-4, that is the Medicare document on how to select the diagnosis code and it discusses how to select the code on the basis of when your findings point to normal outcomes. I highly recommend that you download that document because that is the authoritative guide on selecting a diagnosis code especially when everything is normal.
One of the premises of diagnosis coding is that they have to match who you are, what you did and what you found. But the additional note is they can also match what you were looking for based on signs and symptoms. So, with that in mind, let's go through the rest of questions on this page.
Are we obligated to use the primary diagnosis as the reason to provide or sent the patient to us?
No, let me give an illustration: I have a lot of kids referred to me over time with a diagnosis of meningitis. Meningitis is the basis of concern about hearing but when the child leaves me, my diagnosis should not be meningitis because I did not diagnose meningitis. My diagnosis must be hearing related. If I found a sensorineural hearing loss, my diagnosis could be, for example, 389.10.
If I found normal hearing sensitivity, my diagnosis has to be basically the presenting sign or symptom or concern and in our case, that concern was hearing and so I typically code 389.9 hearing loss and specify on the basis of what I was looking for by virtue of the patient's presenting concerns. So, the meningitis diagnosis can be a secondary diagnosis but the primary must match who you are, what you did, what you found or what you are looking for.
What diagnosis code is used for a child with language delay and has normal hearing?
Your primary diagnosis would not be language delay. Again, following the same idea, if it were me in my clinic, in my evaluation, I would do a 389.9 simply because it has to match who I am, what I'm doing and what I'm looking for.
Diagnosis code for an adult with suspected hearing loss but was normal?
Again, 389.9 under the same rationale as what we talked about above.
What code should one use for example when the PCP refers a child with speech delay for hearing test when no hearing loss is found?
We typically use abnormal auditory perception 388.4, is there a better code to use?
388.4 could be a possibility and there's certainly nothing wrong with that. My own personal preference -- and this comes under the heading of "Fifer's Humble Highly Unbiased Opinion" -- my own personal preference to be to use something in the 389 family simply because you're looking for hearing loss in a traditional sense as opposed to auditory perception.
So, when you code for normal, it could be sign or symptom that's hearing related, typically hearing loss. It can be a presenting concern, again, typically hearing related because that's what we're looking for and the last piece of guidance is do not use a V code to code for a normal outcome.
Coding of hearing aid diagnosis. What's the primary diagnosis? 389.18 or a V53.2?
V53.2 is an ICD-9 code for a hearing aid. I don't recommend that again because it falls in the section generally interpreted as not medically necessary. Whatever diagnosis you find at the end of your evaluation, if it's a 389.10, 389.11, 389.12 or 389.18, whatever diagnosis that is at the end of your diagnostic evaluation, that's the diagnosis that will carry throughout all the rest of the time that you see that patient for the hearing aid, and for any auditory rehab or treatments that you provide to that individual. Again, whatever diagnosis was brought about as a result of your diagnostic evaluation is the one that you use.
Are there advantages or disadvantages to using multiple ICD-9 diagnoses? Is the order of listing important?
In my opinion, there neither advantages nor disadvantages of using multiple ICD-9 codes but for sure there is an order of listing in these codes that is extremely important. Your first code many times is the only one that follows everything all the way through. Now, as of a few months ago, Medicare will now accept I believe up to five ICD-9 codes for diagnosis. But of all of these codes, number one, whatever is first in the listing has to be the report of what you found or what you were looking as a result of your evaluation.
All the rest of the codes can be other symptoms related to hearing loss and can serve to justify what brought the patient to you. But the first code has to be what you're going to use as the basis of justification to report your findings and also for billing.
Can an audiologist use a medical diagnosis code such as otitis media, if this is what he suspected?
No. What we are doing is we are measuring and evaluating function. We are not determining through our testing the medical etiology of the problem and so our primary diagnosis codes must be a functional diagnosis code describing what is their balance, what is their hearing, whatever. It can be the balance family, it can be a 388 for related auditory symptoms and perception, 389 for hearing loss. But it's got to be related to function as opposed to a medical diagnosis.
How specific do we need to be in our overall diagnostic coding such as 389.10, 11 or 12?
You can be as specific as your test results will allow you to be. If you have someone who is 82 years old and has a sloping sensorineural hearing loss, you're not really sure just on the basis of a routine audio whether that is a sensory loss or neural loss or combined, and for me if I were doing it, I would code a 389.10 for combined sensory and neural hearing loss representation.
For someone with acute noise trauma, high frequency hearing loss that comes along with it, you can be assured that things are probably sensory especially if you have unilateral hearing loss and your ABR is normal, that could be your code for sensory hearing loss. If you have something that really looks asymmetrical and clearly abnormal ABR or something along the lines of auditory neuropathy, then the code for neural hearing could be appropriate.
So, the moral of the story is to be as specific as your overall test results will allow you to be. Do not stretch it. Do not report a diagnosis code that you cannot support by your test results and your history combined.
If the patient had otitis media and sees us for a follow up audio at the ENT's request to see if the OM and hearing loss still exists but the child now has normal hearing and type A tymps, can we still use 381.4 as a code?
No, 381.4 should not have been your primary diagnosis code in the first place. Your primary diagnosis code should have been 389.03 - conductive hearing loss middle ear or something comparable with that base upon what you found. A 381.4 could be a secondary diagnosis but not your primary.
Now, when you see the child back and everything is normal in the return visit, then you need to code in according to what you found on that date. And this is where in my clinic I would use 389.9 hearing loss unspecified simply because I'm now looking for a hearing loss that is no longer there. And that's typically what I code when I don't find hearing loss in my particular situation.
If we perform only ipsilateral acoustic reflex test rather than ipsilateral and contralateral, how is our billing code modified?
That would a -52 for abbreviated procedure. The 92568, the code for acoustic reflex is valued on the basis of ipsilateral or contralateral for both ears. If you do only ipsilateral for each ear, basically you did half of the total procedure, you did not modify the protocol but you just didn't do everything and so a -52 modifier would be appropriate there to say: "We didn't do all that we typically do but we did enough that we have some clinical conclusions to make about status of the reflexes outcome."
I want to know about "incident to" billing for VNGs. I have a Medicare and Medicaid numbers and they will bill my number for those patients but the ENT is not enrolled for some third party payers and the neurologist is. He present in the clinic during testing. I work in Missouri, does that make a difference? Can we bill the neurologist number for those other insurances? The billing person thinks that since I'm a licensed audiologist that we cannot.
Living in Missouri really makes no difference as to the answer I give. The premise of it all is that we are recognized by the government as qualified health care providers. Now, if we are not members of a third-party payor network then by rights we really should not see that patient. Now, that's in an ideal world. Everybody should bill under their own number and the situations where they are entitled to bill in the ideal world.
Now, I've been around long enough to know that the real world is not always the ideal world and incident two billing takes place by a physician in the office.
But, if that does happen I want to discourage it. But realistically, if that does happen, here is the requirement: The physician under whom your services are billed must be an active treating physician for that patient and must be the physician who requested those tests.
If that neurologist, in the case of this question, did not see the patient, was not actively involved in the evaluation and treatment of that patient, really had nothing to do with requesting the test, had never seen the patient, it would not be appropriate to use that physician's number to bill;in fact, that would come under the heading of fraud to do so.
I work in ENT and still have one doctor who really likes reflex decay. When I'm marking the charges, do I mark tymps, reflexes, and decay, or does decay assume the others?"
All of the codes, all the procedures, are stand-alone, with one exception, and that is defined in the book. So if you do decay, you've got to mark tymps and reflexes and decay individually on the encounter form for all the elements that you did. Decay does not subsume the rest.
We have one code in our family of codes whereby, by definition, it does subsume other procedure codes;that is 99527. In the CPT manual, it does state, in parentheses, "includes 92553 and 92556." So 57 subsumes 53 and 56. But that's the only one that does. Everything else is very much a standalone code, and you'll mark it based upon what you do.
I work at a hospital where we do ABR for the purpose of identifying hearing loss in babies and young children. We often complete several ABRs, i.e. click, bone conduction, and tone burst ABR at several frequencies. Is it only possible to bill for one ABR for all this testing, if completed in one session?
The answer is yes. All of those activities do come under the heading of 92585, auditory evoked potentials.
Now, if you do this routinely, you need to bill 92585 by itself for that date of service. When we went back for the valuation review for that code, we tried to get more time built in, on the basis that these other activities are commonly done. But neither AMA nor CMS would accept that, and so it is what it is.
Now, if you typically only do a click ABR, and you look at that ABR and say, "This doesn't make sense. I want to do some tone burst ABR to validate and make more sense of this diagnostic."
So you go back through and do a tone burst, and your tone burst comes back really screwy. And you say, "This still doesn't make sense. I need to do bone." So you do a bone conduction ABR. If that is the exception and not the rule, then you can bill a dash-22 extended procedure suffix to your code, and then try to justify to the third-party payer why you want more money from them, why you took so much longer.
And you really need to do it on the basis of validity and interpretability. "On the basis that I did this, it didn't make sense. I did this to validate and cross-check, and that raised a new question that had to be answered by this third procedure. And by doing the combination, it extended the time MUCH greater than what I typically do for this type of evaluation."
But if you're in a pediatric center, like I am, and you typically do these things together as part of your routine, it is not appropriate to bill a dash-22 with a high number of cases, simply to say, "I'm doing this longer than most people do, therefore I need more money." If you do these things, and it's the exception and not the rule, then you could bill a-22 and submit a report to justify why the additional time.
I have some confusion regarding the correct way to bill for OAE testing, comprehensive or unlimited?
This is something that continues to pop up, and your rule of thumb is - if you can count the number of frequencies, it's a screen or a limited. If you count the number of frequencies per octave, then it is a diagnostic. Now, the comprehensive versus limited are AMA terminology on how things have to be labeled. 92587, which is the Otoacoustic Emissions - Limited was designed from day one for newborn hearing screening. We don't use the word "screening" simply because screening has its own connotation, typically it's not reimbursable, but 92587 was developed on the basis of newborn hearing screen. But by AMA terminology, it has to use the word "limited."
Now also be aware that these codes came about in 1994, at least the diagnostic code did, and at that time the state of the science was to compare transient or click-evoked OAEs with distortion product OAEs or to do click-evoked at more than one intensity level or distortion product at more than one intensity level. That was then, this is now. Things have evolved to the point that we don't compare click-evoked and distortion anymore, or at least not very often, to say "I had to do this in order to learn about the status of the cochlea." Rather, what we do, what has evolved - and the literature supports this, is we are mapping the cochlea now, and that constitutes a comprehensive.
So if you do four points per octave, from 500 Hz through the limits of your equipment, then that is indeed a comprehensive. If you do six points per octave, that's really a comprehensive. I've come across a few that do ten points per octave. That's really a comprehensive. But if you count the number of frequencies, that's a screen or a limited. If you are looking up frequencies per octave over a very broad range, that can be justified as a comprehensive under the current use of OAEs.
Now that we have the NPI number, do we stop using Medicare and Medicaid numbers?
Yes. Medicare will have a good idea of who you are with your NPI number simply by virtue of they were the ones to issue it to you. (However, I recently came across a bulletin that said you need to crosswalk your Medicare number with your NPI number to ensure that your state level carrier knows who you are.) Your Medicaid, however, is a little different story in that you may need to notify your state Medicaid Office that this was your old Medicaid Provider Number and this is your new NPI number and you're going to start using it now in the claims so that it will recognize you as one in the same person.
For all third-party payers, you've got to notify them and reference your old provider number to the third-party payer and with your new NPI number in order for them to recognize who you are. With private, commercial third-party payers, don't just start using your NPI because they'll have no clue who you are. You've got to notify them that you have this number now and make sure that they have cross-referenced it.
The ENTs in our office do not participate with Medicare. Can you provide any insight?
There are providers who do not participate in Medicare, and that does not mean you cannot see Medicare patients, but that does mean that you are under a different set of rules to do so. You're called non-participating providers. What I recommend to you is to go to the CMS web site - cms.hhs.gov - and in the search box type in non-participating providers, and it will give you a broad generalization of guidelines that you need to abide by in order to know what to do and what not to do to remain right with Medicare.
Is there any way to bill for attending school-based IEP meetings, providing in-services to preschool teachers as well as functional listening evaluations?
No, there is not. First of all, there are no codes to do so. The team conference code is coming out. Conceivably on a stretch it can be used for IEP meetings, but then the question would be, "Who are you going to bill?" because you've got a mismatch in those particular functions, between desire to bill and who's going to pay the bill. And if you have a contract with the school and the school's agreed to pay you, well then, good. But most insurances will not, and they don't recognize those as falling under the heading of "medical necessity."
If you do a functional listening evaluation for a hearing aid, potentially, that is, billable as a conformity evaluation or a follow-up. But I would recommend do not just stick the kid and do aided, unaided, and sound field, without also doing some real-ear measurements and some other measurements, to really validate and justify a conformity or a follow-up evaluation of the hearing aid.
Can an audiologist with an Au.D. bill differently than a non-Au.D. audiologist, to improve or increase reimbursement?
You can bill whatever you want. What you get paid is a different story. Now, having said that, for both Au.D. and non-Au.D. audiologists, what you need to do is to be able to justify whatever you bill based upon your cost of service delivery. And you've got to calculate this on a per-hour or a per-procedure or a per-patient basis, to know several things.
Let me digress. The elements that you need to include would be the annualized wages for any support staff, your utilities, your rent or mortgage, your insurances, your licenses, the equipment depreciation, office supplies, etcetera, etcetera. Your salary, by the way, is an important part of that. And include benefits, if you provide health insurance and other benefits for yourself and for your staff.
You also have to have an increment in there called profit, to know how much profit you want to try to make for the practice, and also cash reserve, because you do need to have a cash reserve for your practice. Cash reserve serves a number of purposes for bad debt, for equipment replacement, and for a number of different things.
And you've got to know how much this is going to be, in order to know how to set your billing rate. That will vary from one part of the country to another. It'll vary based upon if you are inner city versus suburb. It'll vary based upon if you're city versus rural. But you've got to justify what you want to charge based upon how much does it cost you to provide the service, how much markup do you want to include in it all, for profit, and also for equipment replacement and planning ahead.
We seem to have a multitude of billing problems with Blue Cross Blue Shield. The latest is the Medicare Advantage program in Michigan.
My comment to that is welcome to the club. Blue Cross Blue Shield plays a game. Here's how the game works. Blue Cross says that "We will cover hearing services." Now, that sounds really good, doesn't it? But the caveat is "We will cover hearing services, only if they are provided by a medical doctor. If the hearing services are provided by someone who is not a medical doctor, we will not cover them, on the basis of the qualifications of the provider of those services."
Here is my own personal example. I have a Blue Cross provider number for Florida. If I receive a patient and I bill Blue Cross, I am denied because of who I am. If a physician with an MD bills the same services, they will pay. We've had conversations with them, but to no avail. And Blue Cross tends to play this game in virtually every state, to some extent to another. If they don't play this game, you're the exception and not the rule, and you are very fortunate.
Evidently, Blue Cross and Medicare are combined now for some groups. Because of the change we have not received reimbursement from Blues for patients under this plan for several weeks. No one seems to know why, whether it's an EDI issue or our NPI numbers, etcetera.
Medicare and the Blues are combined in many states. That does not mean that they are one. What this refers to is that Medicare, in most states, has contracted with a local insurance carrier within that state to be the intermediary between the provider and Medicare.
Many times, the carrier is a subsidiary of Blue Cross Blue Shield. For example, in Connecticut and Florida, First Coast is the carrier for Medicare services in both of those states. Empire, in New York, is the carrier there. And I'm not sure what it is in other states, but most often, it's quite common for that carrier to be either a Blues or a subsidiary of the Blues.
Now, if you're not getting paid and you were previously, then what I suggest is to call the provider liaison and have that person help track down for you what the issue is why you're not getting paid, because, with your contract as a provider with that payer, they are obligated to make sure that everything is appropriate, that everything is fair, within the definition of the contract, to both sides.
So call the provider liaison. That person is found at that carrier's headquarters within your state. When you call them, you'll get a general number. Say, "I'm an audiologist. I want to talk to the provider liaison about some issues regarding submission of payment of services." You also need to check to make sure that they have your NPI number cross-referenced with your old provider number and make sure everything's straight there.
What is the qualifier, when filing Medicare for hearing aids, to get a rejection so the secondary coverage can pay it?
That is a GY modifier. This is another one where I recommend going to the Medicare website, because GY is one of a couple of different modifiers you need to know about.
There's a GA modifier for letting Medicare know that the patient has signed an advanced beneficiary notification. There is a GY modifier, when you know it's going to be denied, but it serves a purpose. There is also a GZ modifier. So go to www.cms.hhs.gov, and in the search box, type in "GY modifier" because when you find that, you'll typically find the documentation for the other modifiers as well.
And so, on your CMS-1500 form, there is a box there for modifiers, and you'll simply put in "GY." This tells Medicare, "I know this is statutorily denied, but I need to have you deny this claim so another third-party payer covering this patient will pay for the service." And Medicare's fine with that.
GY modifier may also be used when the patient's secondary insurance depends on a Medicare denial. Most claims submitted with a GY modifier will be denied automatically by the carrier or a fiscal intermediary. With these cases, a beneficiary will be liable for the charges. And that's an important statement for you to know.
What's Medicare and other insurance companies doing about the Otogram?
Not a whole lot, and here's the reason why. Medicare does not like the Otogram. I have had many conversations with my contacts in Baltimore. They do not like the Otogram, and the reason that they don't like the Otogram has nothing to do with the reliability of the device, although that is part of it.
The reason why they don't like the Otogram is because our procedures are valued on the basis of personal delivery of professional services to every patient. They are not valued on the basis of machine delivery or machine gathering of information only. And so it violates the AMA Guidelines, it violates the Medicare CMS guidelines for reimbursement for those CPT Codes.
Here is one other little tidbit of information - Under the previous owner of the Otogram, in the small print in the literature it stated that these results must not be used for diagnostic purposes, which by definition stated on the literature advertising the Otogram, that would throw it into a screening realm, and screenings are not authorized reimbursement. So the Otogram technically is not authorized reimbursement. (As an updated note, an article appeared in the October issue of CPT Assistant - an AMA publication, stating that the Otogram should be reported under CPT code 92700 for all component procedures associated with that device.)
There have been some billings where primary care physicians go sky high with the Otogram. I do know a few of them have been visited by auditors, and I don't know the outcome of the audits, but Medicare is looking at it but only where things really look suspicious. They really have no other way of knowing right now, when a bill is submitted whether it came from an Otogram or a personal delivery of services, and that is what's stumping them in terms of doing anything about it at the present time.
I work in an outpatient hospital setting. Which of our audiology diagnostic CPT Codes can be broken down into and billed individually as technical and professional components?
In your particular setting as an outpatient hospital setting, none of your codes can be broken down into PC or TC components. And the reason why is because when you do your encounter form, you check off 92557, 92567, 9268, etc.
What you don't realize is that you come under a different reimbursement paradigm compared to a private practice office or a physician's office. Outpatient hospital settings fall into the rules for the Outpatient Prospective Payment System (OPPS). Under that system the CPT Codes are converted into Ambulatory Payment Codes (APCs), and what that means is that...let's take 92543-Caloric ENG. We normally bill that in units, and some parties pay $25 apiece for each unit, or some parties pay $15 apiece. Under OPPS, 92543 is reimbursed somewhere in the neighborhood of a flat $97 regardless of how many calorics you do and how many units you bill. It's a flat $97 and some change or thereabouts.
If I remember correctly, 92542 - the positional, gets converted to the same APC Code, and it's also reimbursed at a flat $97, the same reimbursement rate as caloric ENGs, as is optikinetic, as is all the rest. And so the CPTs are taken and converted into a different coding category for categorical reimbursement based upon the APC level. Because of that, you really can't break them down into TC and PC components just by virtue of the fact that you're an outpatient hospital setting and the rules that govern your reimbursement under the Outpatient Prospective Payment System (OPPS).
Why is it that the New York State Medicaid Department will not cover the cost of ENG testing as performed by a licensed and certified audiologist? Medicaid is usually the secondary payer anyway for many of our ENG Medicare patients.
Well, the only thing consistent about Medicaid from state to state is that there is nothing consistent about Medicaid from state to state. The state legislature and the state Medicaid Office has tremendous input as to what services they will cover and also how they will cover them.
Now, there's another little twist thrown into this question when the Medicaid patients are also Medicare eligible. As a licensed audiologist Medicare provider, Medicare should reimburse you based upon what you did and the fact that you are a qualified healthcare provider in the Medicare System. Medicaid, however, does not have to recognize you for every procedure, and in most states audiologists are not recognized for every procedure. It's sort of a cafeteria mode in that some states recognize audiologists for some things, not for others and what audiologists are recognized for will vary from state to state. It comes down to a matter of the state Medicaid Office and your legislature both have a lot of say as to what's covered and what is not, and that's the reason why you may not be recognized for a procedure by the state Medicaid Office even though you should be by federal Medicare.
Can you talk about method codes?
Under the AMA Rules, there is no such thing as a method code. For example, if you billed 92557 (Comprehensive audiometry), you cannot also bill 92579 (VRA) to say "I did a diagnostic audiological evaluation using the method of visual reinforcement audiometry." Doesn't exist by AMA definition. Every code has to be a complete self-standing, non-overlapping procedure code. Here are some examples:
92557 - Comprehensive audiometry. Pure tone, air and bone, SRT and word recognition.
92579 -VRA. The audiogram obtained using visual reinforcement techniques.
92582 - Conditioning play audiometry. The audiogram obtained through the technique of condition play.
92553 - Audiometry, pure tone, air, and bone
As I mentioned in the example above. It is not appropriate to bill 92557 and 92579. Now, having said that, I've had several people email me and say, "Well I've been audited and I bill 57 and 79 all the time and nothing was said in the audit." Well, this falls under the heading of "Rather be Lucky Than Good" because you had an auditor who really did not understand our codes. It is not appropriate under AMA, nor is it appropriate under CMS guidelines to bill 57 and 79 together on the same date of service.
Now this person says, "I check the edits list and cannot find them to be exclusive of each other." That is true. It is possible sometimes that you would do a 57 and 79 completely repeating each procedure independent of the other. Or you might do a 53 using standard procedures, and then a 79 when things don't make sense for what you got for pure tone, air, and bone under the hand-raising technique.
Or, if you did conditioned play, 82, and you look at your results and say, "This really does not make sense. I got a full audiogram with pure tone, air, and bone, using conditioned play, but it really doesn't make sense to me. I need to cross-validate this using VRA." So you take the child in and do a complete VRA, 79, to recreate the audiogram as a cross-reference to what you got through conditioned play. Your documentation has to justify why you did one complete 82, and then why you went and did the other complete, 79. And there are certain occasions where it's justifiable on a case-by-case basis, but on a routine basis, it is not appropriate to bill 57 and 79 in combination or 57 and 82 in combination, because you are, in effect, double-billing for the same procedure.
The reimbursement level notwithstanding, that's a different story. But procedural-wise, it's not appropriate to bill the two together. And there is no such thing as a method code.
What is your expectation regarding coding for pediaudiology? Not just a quickie sound field screen. How do we indicate that we've done air conduction and bone conduction SATs, but also use VRA or conditioned play to obtain these results?
This is a similar question to the previous. Here's another tidbit for you. If you do a complete audiogram by air conduction and bone conduction, whether it be by sound field visual reinforcement or insert phones, if you use a VRA technique, you would have your choice of billing either 92579, for VRA, or a 92553, for pure tone, air, and bone. You can bill either one, and your results would justify billing either one, but it would not be appropriate to bill both.
That reminds me to tell you is that for 92579 (VRA), speech awareness threshold IS included in the valuation of that procedure. But for 92582, the conditioned play audiometry, speech testing is not included in that code.
So if you did conditioned play, got your audiogram, and then turned around and got your speech reception threshold, you can bill 92582 and then 92555, for speech threshold testing. But, as I mentioned previously, when evaluating children, it is appropriate to bill both 92579 and 92582 when you do both--only if you have justification for doing both.
Now, to expand on what I talked about earlier. For example, let me give you a situation I encountered about two or three weeks ago. I had a child, it was a low functioning five-year old that started off with play audiometry. There is no way this kid would do standard testing, so I started off with play audiometry. I got one pure tone threshold estimate, and then it was obvious that this kid just wasn't getting it. And so I stopped at that point and switched to 92579, and got pretty much a complete audiogram, using 92579.
Now, I did not bill 92582. And the reason why is because, even though I did some of that procedure, I did not get enough information for any clinical interpretation of my results. 92579 was what I billed because, with that procedure, I did get enough information to have a clinical assessment, a full interpretation of what does it mean.
So the guidance I would offer -- and this is Fifer's experience and Fifer's opinion, as opposed to any official AMA ruling -- is if you get enough information for a clinical interpretation and then you find that you have to change procedures for some reason, then I would bill both of them. And I have done that. But I have also documented what caused me to want to change procedures to whereby I did both conditioned play and VRA. That doesn't happen very often.
I do not recommend a full regimen, routinely, of both VRA and conditioned play, simply because, once you have a lot of information from one, the information from the other really no longer falls under the heading of medical necessity. And my concern is a possibility of getting dinged on an audit, should someone come to pay you a visit.
We currently have a copy of a summary of audiological CPT codes and description of uses, prepared by another expert in the field. Do you have an updated version or one similar?
Yes, of course I do! Not one from Bob Fifer. I have what's called the 2007 CPT Manual. And that's a complete list of CPT codes, and for some of the codes, a supplemental description of their uses.
In addition to that, what I recommend for your consideration is another publication by the AMA called the "CPT Assistant." What the "CPT As
