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Coding for normal hearing and the use of other diagnosis codes.

Robert C. Fifer, PhD

August 7, 2007


Question

Coding for normal hearing - can V65.5 be used?

Answer

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 That code no longer exists and has been replaced by V72.11 and V72.19.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 nd this comes under the heading of "Fifer's Humble Highly Unbiased Opinion" y 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.


Robert Fifer, Ph.D., is the Director of Audiology and Speech-Language Pathology for the Mailman Center for Child Development at the University of Miami School of Medicine. He is also an Audiology Online Contributing Editor in the area of Coding and Billing. He is 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.

Editor's Note - The above is a partial transcript from the Coding and Billing QNA Live e-Seminar that was conducted on Audiology Online on June 27, 2007. (The recorded version is available here - Also the complete edited transcript is available here. The format of the session was different from most traditional presentations as we solicited questions ahead of time and also solicited questions during the event and had Dr. Fifer focus on answering those questions during the live session. We have published the transcript from the seminar in a semi-rough format to preserve the live feel from the session and to accelerate the publication timeline of this information to the Audiology Online readers. Submitted questions are bolded, followed by Dr. Fifer's response. Dr. Fifer is a frequent Contributing Editor for Audiology Online in this area, look for additional Coding and Billing QNA sessions on our home page in the near future. - Paul Dybala, Ph.D. - Editor


robert c fifer

Robert C. Fifer, PhD

Director of Audiology and Speech Language Pathology at the Mailman Center for Child Development at the University of Miami

Robert C. Fifer, Ph.D. is Director of Audiology and Speech Language Pathology at the Mailman Center for Child Development at the University of Miami.  Dr. Fifer represents ASHA on the AQC. 


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