the basics of CPT

CPT® is an acronym for Current Procedural Terminology. CPTs are 5 digit numeric codes, created and owned by the American Medical Association, to describe medical services and procedures. (Most audiology-related codes begin with the numbers 92-.) These codes are added, deleted, and modified annually. As ancillary medial professionals, it is important for us to consider that CPTs are created by the AMA, especially when we question the presence or absence of particular codes or procedures.

When it comes to CPT codes one basic premise applies: always select coding which legitimately represents all of the procedures that were completed on each individual patient. Remember, third-party payers, particularly Medicare, cover only the procedures needed to diagnose an otologic or auditory disorder in a patient. “Routine” services are typically non-covered. For this reason, use of an Advance Beneficiary Notice is essential. The Advance Beneficiary Notice allows your practice to bill Medicare recipients directly (privately) for non-covered services (i.e. routine audiograms, audiograms for the purpose of obtaining a hearing aid, cerumen removal).

As of October, 2003, HIPAA will require that all insurance carriers, including Medicare and Medicaid, use CPTs to report the testing or procedures that were completed. Therefore, it is imperative for all audiology practices to be current on CPT codes and their application.

CPT TIPS

• Use various coding combinations to legitimately increase reimbursement, especially in certain situations such as pediatric testing, central auditory processing evaluations, vestibular testing, and cochlear implantation.
• It is completely legitimate to bill for procedures that were attempted, but where no data could be gathered (such as conditioned play audiometry where the child would not condition). Document the situation in the patient’s file and/or on the audiogram form.
• Do not unbundle procedures as it may result claim denial or reduced reimbursement.

EXAMPLE
Do not bill 92553 for pure-tone air and bone and 92556 for speech awareness threshold and speech recognition rather than 92557 for a comprehensive audiogram, which includes the two former procedures.

• Do not use CPT codes that are not specific to audiology/otolaryngology services. Use of these codes will result in claim denial. In the case of Medicare, audiologists cannot bill for Evaluation and Management codes; however, they are acceptable codes for many private carriers. As a manager of Hearing and Balance care you may bill Evaluation and Management codes. Your report to the patient’s physician should include the following sections: History, Diagnosis, and Treatment.

EXCEPTIONS

• If you are billing for intraoperative monitoring, cerumen removal, or canalith repositioning. Request a signed Advance Beneficiary Notice in these cases as you will probably be denied for all or part of the charge.
• If there is no CPT code for the service the audiologist is providing, use 92700 (Unlisted otorhinolaryngological service or procedure). When filing the claim, include a full description of the procedure and documentation supporting its need. Also submit a fee that reflects what the procedure is worth. Consider having the patient private pay for these services.
• Require patients to private pay for services that have no billable code (i.e. canalith repositioning, tinnitus evaluation and retraining, certain central auditory processing procedures)
• Per Medicare, audiology procedures possess both the technical and professional component and, as a result, the global code should be billed to insurance carriers.
• Use modifiers to better illustrate the services provided to ensure appropriate reimbursement. Most audiology codes imply that both ears are being tested.

EXAMPLE
Patient F is having a post-op hearing evaluation on his operative ear only. If Audiologist G billed for 92557 he/she must add a –52 modifier (Reduced services) to reflect that only one ear was tested.

• 92586 (ABR; limited) and 92587 (OAE; limited) are screening measures, often used in infant screening
• 92585 (ABR; comprehensive) and 92588 (OAE; comprehensive) are clinical or diagnostic measures * Make sure you fulfill all of the criteria of 92588 (multiple levels and frequencies)
• Bill 92547 (Use of vertical electrodes) as many times as needed in association with each ENG code (92541-92546); if it is clinically useful to you to have vertical electrodes in place, bill for those procedures. The use of this code is only appropriate if doing ENG testing. It is inappropriate to use this code to reflect the use of goggles in VNG testing. If using goggles, bill 92700. ( This code is used to bill procedures which do not have a CPT code. Create supporting documentation that includes a complete description of the procedure, its diagnostic or rehabilitative value, any equipment that is needed, the time it takes to administer, and any special knowledge required to administer. Create a fee that represents the cost of your time, overhead, and equipment in performing this procedure. Send this documentation with any denial.)
• Medicare does cover ear protector evaluation measures (92596)

If you have any specific questions, visit the reimbursement forum or send an e-mail to the ADA Help Desk.

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