So that we can keep Audiology Online readers up to date on various coding issues this article has two sections. The first section is an overview of the most recent AMA Current Procedures Technology (CPT) code changes for 2006. The second section is a collection of answers to commonly asked questions about coding provided by Dr. Fifer.
Lastly, if you would like additional background information on audiology coding, Dr. Fifer published an excellent summary article available on AO.
Fifer, R.C. (2002, April 2) Professional Coding: Parts 1, 2 and 3. Audiology Online, Article 346. Available via the Articles Archive on https://www.audiologyonline.com
- Paul Dybala, Ph.D. - President and Editor, Audiology Online.
New Audiology CPT Codes for 2006
There are several changes to the AMA Current Procedures Terminology (CPT) manual (AMA, 2006) as relates to audiology for 2006. These included four new codes that focus on auditory (aural) rehabilitation, the deletion of an aural rehabilitation code for cochlear implants and the revision of two codes for acoustic reflex testing.
Auditory (Aural) Habilitation Coding History
Aural rehabilitation code proposals were originally presented to the AMA in February 1995 with the goal of having a diagnostic code and also a treatment code. The description of the treatment code highlighted post-hearing aid fitting orientation and intervention. Martin Robinette, Ph.D. (representing ASHA) and I (representing AAA) presented arguments before the AMA's CPT Editorial Panel (AMA, 2004) and were partially successful. The panel members were convinced of the need for these codes, but they were afraid of the CPT manual growing too rapidly through the addition of so many new codes. A unilateral compromise was offered in that the procedure request would be granted, but not in the form of new, independent CPT codes. The diagnostic code would be combined into CPT code 92506 (Speech/hearing evaluation) and would read, "Evaluation of speech, language, voice, communication, auditory processing, and/or aural rehabilitation status." (Note that this was the same year that we initially tried to obtain a new CPT code for auditory processing.) The treatment portion of aural rehabilitation was rolled into 92507 (Speech/hearing therapy) which became, "Treatment of speech, language, voice, communication, and/or auditory processing disorder (includes aural rehabilitation); individual." The AMA's intent was that these codes should be multi-disciplinary, multi-use procedure descriptors available to both speech-language pathologists and audiologists.
The new codes were indeed available for audiologist's use for the first two years after publication in the 1996 CPT Manual. But then the Center for Medicare and Medicaid Services (CMS) organized their job classification listings for diagnostic versus rehabilitation professions and assigned CPT codes to the various health care specialties. Speech-language pathology (SLP) was decreed to be rehabilitation; audiology was designated diagnostic. Because 92506 was primarily a speech and language code by virtue of its descriptor and reporting volume, it was placed off limits to audiologists and designated an SLP code only. At that same time, CMS decided that aural rehabilitation (or any other form of rehabilitation) would not be reimbursable to audiologists because of the "diagnostic" classification. In 2005 we were successful in obtaining two new CPT codes for auditory processing and so we focused on aural rehabilitation for this year's book.
92626 - Auditory Rehabilitation
The first thing that audiologists should notice about CPT code 92626 is that the name is no longer aural rehabilitation. It is now called auditory rehabilitation. This was done to broaden that range of activities for which this diagnostic procedure could be used. Aural rehabilitation acquired the connotation of being associated strictly with individuals who were obtaining hearing aids. CMS further complicated matters by placing another restriction onto the definition of "aural rehabilitation": speech-reading only. Whereas speech-reading may be one element of the evaluation of auditory rehabilitation status, the intent is to do much more. The description of activities for this code as stated on the CPT application is as follows:
- Whereas the audiogram is intended to yield information regarding hearing loss (i.e., pure tone thresholds) and a gross measure of speech understanding, an auditory (aural) rehabilitation assessment in children is designed to evaluate their progress with respect to learning how to hear, the discrimination and identification of environmental sounds, identification of speech sounds, and progression toward the identification of words and learning how to listen with noise in the background. Similar assessments are applicable to adults who have recently received a hearing aid or cochlear implant. In both cases, the objective of the assessment is to determine current abilities in preparation to teach them how to use residual hearing provided by a cochlear implant or hearing aid. For adults who have received a new hearing aid or a change of hearing aids with different acoustic characteristics, the emphasis of the assessment is to determine the magnitude and type of communication difficulties experienced by the patient in order to know which communication strategies must be taught. Another type of assessment for auditory (aural) rehabilitation focuses on determination of need, selection, and applicability of assistive listening devices or other complementary equipment. In both children and adults, the assessment addresses dimensions of impairment, activity limitation, participation restriction, and applicable environmental and contextual factors.
Timing Considerations for AR Codes 92626 and 92627
The second thing that audiologists should notice is that 92626 is a timed code for the first hour. This required a second, companion code 92627 for each successive 15 minutes. The basis of "timing" this evaluation procedure was that no "typical" or "median" time exists by which an evaluation could be completed. Young children may take a relatively short time, whereas adults may require more assessments to determine their status. A young pre-implant child may be very limited in what can be done compared to a post-implant child with considerable listening experience. For these reasons, the proposal was made and accepted to make this assessment code a timed code.
Timed codes require a little different documentation than do "contact" codes. In addition to the history, description of procedures, clinical assessment and recommendations, clinicians must also list the "start" and "stop" times in the chart (i.e., "Session started 3:00; session ended 4:20"). This element of documentation is needed to justify the times used that were billed. In the example cited above, one unit of 92626 for the first hour and one unit of 92627 would be billed for the next 15 mintues. The clinician would need to go beyond the first hour and at least eight minutes into the second time block to bill a unit of the second 92626 code. In order to bill two units of 92627, the total time would be greater than one hour 23 minutes. Because it was one hour 20 minutes, only one unit of each would be billed.
92630 - Auditory Rehabilitation: Pre-Lingual Hearing Loss
The third code is strictly an intervention code intended for therapeutic activities with patients who have pre-lingual hearing loss (92630 - Auditory rehabilitation: pre-lingual hearing loss). The proposal justification as listed on the application for this code included:
- When children are diagnosed as hearing impaired and receive either a hearing aid or a cochlear implant, it cannot be assumed that the use of only the amplification device (hearing aid) or neural stimulator (cochlear implant) will be sufficient unto itself to allow the child to hear and understand speech in a manner appropriate to develop language. They must be taught how to hear beginning with sound identification and discrimination between two sounds, identification of distinct speech sounds, and eventually learning how to understand speech. The basis for the necessity of this instruction is that neither hearing aids nor cochlear implants restore normal auditory function. .... Consequently, training is necessary, especially for children, to teach them how to hear using these devices to overcome the effects of an impaired auditory system. As implied above, this type of training is also necessary for some adults to facilitate and accelerate their learning to use this new type of auditory input.
92633 - Auditory Rehabilitation: Post-Lingual Hearing Loss
The last code, 92633 - Auditory rehabilitation: post-lingual hearing loss, is designed to cover the activities associated with either hearing aids or cochlear implants for individuals who had hearing and lost it. The CPT code application description included:
- ... by way of intervention, we now have available numerous techniques and compensatory strategies to teach the individual how to manage the environment, combine sensory inputs (visual plus audition), incorporate listening strategies, and optimize amplification characteristics of the hearing aids / cochlear implants according to the patient's specific needs. The teaching of these techniques to the hearing impaired individual is the focus of this service.
Valuation of 92630 and 92633
92630 and 92633 were not valued by Medicare because they will not pay for audiologists to provide rehabilitation type services. Interestingly, in the final rule for the 2006 physician fee schedule, Medicare stated that speech-language pathologists (SLPs) cannot use those codes either. SLPs were directed to use 92507 (treatment of speech, language, voice, communication, and/or auditory processing disorder) for all rehab-related activities. From the correspondence I received from one audiologist for whom 92630 in particular is very important, that could potentially be a good thing. She told the insurances that 92630 is the new code to replace the deleted code 92510 (auditory rehabilitation following cochlear implantation). The insurances then transferred the payment amount that they were offering for 92510 over to 92630. What this means in general, however, is that these codes are open for each audiologists to price them as they see fit and to negotiate prices with third party payers without any potential hindrance of Medicare pricing.
92510 - Auditory Rehabilitation Following Cochlear Implantation Code Deleted
Code 92510, Aural rehabilitation following cochlear implantation (includes evaluation of aural rehabilitation status and hearing, therapeutic services) with or without speech processor programming, has been deleted. The processor programming had already been removed from this code and had evolved into CPT codes 91601 through 91604. The aural rehabilitation portion of 92510 may now be captured in either of the intervention codes (92630 or 92633).
92568 and 92569 - Reflex Decay Codes Revised
CPT codes 92568 and 92569 were revised to clarify that the acoustic reflex threshold procedure is distinct from reflex decay. The old description (Acoustic reflex testing) was quite broad and lent itself to various interpretations such as also including acoustic reflex decay. The new descriptor for 92568 now reads "Acoustic reflex testing; threshold". And the new descriptor for 92569 now reads "Acoustic reflex testing; decay".
Coding Questions and Answers
These are a series of questions that I have received as they relate to coding for audiology. They are presented with my answers as more of a general discussion on coding as opposed to a comprehensive resource. The reader is encouraged to consult the 2006 CPT Manual (AMA, 2006) (available at https://www.ama-assn.org) for more information.
Question:
I have a question about billing for an ABR. I currently use multiple stimuli (clicks and frequency specific tone bursts) and perform threshold testing in each ear when I evaluate infants. I know that 92585 is the code for ABR but how should I use it when I am testing threshold at multiple frequencies?
Answer:
You are correct that 92585 is the code for ABR. It is actually the only code, although we are working on obtaining a new code for ASSR, but this will take a while as it does not meet all the criteria yet for the AMA granting a new code.
At our most recent review of this code in March 2004, we tried to get approval from the AMA for increased evaluation times to account for the additional testing that you describe. The AMA would approve some additional time (approximately 15 minutes), but they would not approve a lot of extra time such as what was needed for an ABR, an MLR and an ASSR or combinations thereof. The AMA was interested in the "typical patient", which ended up being for kids a single threshold search in each ear and for adults a diagnostic ABR and an MLR.
Question:
I was wondering what the CPT code is for canalith repositioning maneuver?
Answer:
There is not a CPT code for canalith repositioning. Most professionals, including audiologists and physical therapists will use 97112. This is a therapeutic exercise code for neuromuscular re-education. It focuses on balance for standing, walking and sitting and the code is billed in 15 minute intervals.
Question:
What is the difference between CPT and ICD-9 codes?
Answer:
A Current Procedures Terminology (CPT) code is a procedure such as an ABR or reflex testing. The International Statistical Classification of Diseases and Related Health Problems (usually abbreviated as ICD) is in its 9th revision. The ICD-9 is a diagnostic code such as 388.30 for tinnitus, unspecified.
Question:
What is the diagnostic code for auditory neruopathy? I was not able to find a code specific for AN.
Answer:
You have several codes to choose from for neuropathy: 389.18 (sensorineural hearing loss of combined types) or 389.12 (neural hearing loss) or 388.5 (disorders of the auditory nerve, including degeneration of the auditory nerve).
Question:
Are there any billing codes for automated hearing testing? How is automated testing differentiated from direct contact? Is automatic testing only considered a screening or is there a diagnostic code for this type of testing?
Answer:
Medicare will not pay for audiology services unless they are personally delivered with face-to-face contact with a patient. The problem that we have seen is that computerized billing systems have no way of telling if a person was seen face-to-face (attended care) or not (unattended care). We have had discussions with the AMA about "unattended" codes for audiology. This area is new to the CPT system as the joint AMA/Medicare valuation guidelines have been based on attended care. Psychology just obtained new codes to replace their current codes. There was a long discussion about the valuation of services provided directly by a psychologist, a psychometrist or a computer. Interestingly, Medicare valued the personal administration of a psychology test at 2.74 RVUs, while tests administered by a computer were valued at 0.74 RVUs.
Question:
If I bill 92557, is there a specification for "traditional" audiometry? When I bill 92557, I have typically tested at 9 frequencies (.125, .25, .5, 1, 2, 3, 4, 6, 8 kHz). I have also seen persons who bill 92557 and only test 6 frequencies (.250, .125, .5, 1, 2, 4, 8 kHz). How is 92557 defined?
Answer:
92557 is valued on the basis of a minimum of octave frequencies from .25 kHz through 8 kHz for air conduction testing, .25 kHz through 4 kHz for bone conduction testing and also includes SRT and word recognition testing.
About Robert Fifer:
Robert C. Fifer, Ph.D. is currently 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 received his B.S. degree from the University of Nebraska at Omaha in Speech-Language Pathology with a minor in Deaf Education. His M.A. degree is from Central Michigan University in Audiology. And his Ph.D. degree is from Baylor College of Medicine in Audiology and Bioacoustics. Dr. Fifer's clinical and research interests focus on the areas of auditory evoked potentials, central auditory processing, early detection of hearing loss in children, and auditory anatomy and physiology. He is the current President of the Florida Association of Speech-Language Pathologists and Audiologists, 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. Additional responsibilities at the state level include serving as a consultant to the Florida Department of Health's Children's Medical Services and the audiology representative to the Genetics and Newborn Screening Advisory Council. Dr. Fifer is an Audiology Online Contributing Editor in the area of Practice Management.
Works Cited
American Medical Association (AMA) (2004, November 24) How a Code Becomes a Code. Retrieved February, 6, 2006, from https://www.ama-assn.org/ama/pub/category/3882.html
American Medical Association (AMA) (2006) CPT Manual. Chicago, Illinois: American Medical Association.
