Rethinking the Audiometric Test Battery?
AudiologyOnline: Why are you suggesting that we don’t need to always use CPT code 92557 when we conduct diagnostic hearing assessments?
James W. Hall III: Analysis of Medicare data does indeed confirm that audiologists most often use the 92577 CPT billing code, at least in older adult patients. In conducting hearing assessments, audiologists should perform tests that are “medically necessary,” that is, necessary to prevent, diagnose, or manage a disorder, condition, illness, or disease. There should be published peer-reviewed scientific evidence in support of the application of each of the tests applied with every patient. In addition, procedures included in the test battery should be reasonable and appropriate for the audiologic diagnosis and management of an individual patient. The tests encompassed within CPT code 92557 (air and bone conduction pure tone audiometry and simple speech audiometry) don’t always meet accepted health insurance coverage criteria. In fact, one could argue that some tests, like bone conduction pure tone audiometry, is not reasonable, appropriate, or necessary for a rather sizeable portion of adult patients in a typical audiology practice.
AudiologyOnline: How do you decide what tests to perform on a specific patient?
James W. Hall III: The first step in deciding what tests to administer is to consider the patient’s history and chief complaint. What previous health problems and treatments does the patient report, and what patient concern prompted the patient to seek out your services? Patient history largely determines what tests you will include in your diagnostic battery and, equally important, tests that are not reasonable, appropriate, and/or necessary for a particular patient.
A few examples might be useful in answering your first two questions. Let’s say your patient is an adult with a chief complaint of hearing loss, especially in noisy settings, plus annoying ringing tinnitus. He or she has no history of middle ear disease and has never seen an otolaryngologist. The referring physician’s report confirmed normal ear findings upon physical examination. According to the report, diabetes was the patient’s primary health problem. Based on patient history and chief complaint, the most effective test battery would include aural immittance measures (tympanometry and acoustic reflexes) to unequivocally rule out middle ear dysfunction, and procedures with sensitivity to cochlear function and to speech perception in noise. For this patient, spending test time with bone conduction pure tone audiometry, and billing for the procedure, would not seem reasonable or necessary for diagnosis or management.
AudiologyOnline: If I don’t always conduct bone conduction pure tone audiometry and measure speech reception threshold, what other tests would you recommend?
James W. Hall III: Again, recommended tests are based on the patient’s history and chief complaint (s). OAEs are an objective and sensitive measure of cochlear function. Therefore, OAEs are a reasonable, appropriate, and necessary test for patients at risk for cochlear dysfunction and sensory hearing loss, including those reporting tinnitus, patients with a history confirming one or more diseases associated with cochlear abnormalities (e.g., diabetes, kidney disease), or with lifestyle risk factors for sensory hearing loss, such as diet, noise exposure, and/or smoking. Assessment of speech perception in noise is, obviously, appropriate, reasonable, and necessary for proper evaluation of any patient who complains of difficulty communicating in noisy environments, and also for older adult patients with a history suggesting cognitive decline or impairment including dementia. Middle ear disease is highly unusual in adults. Nonetheless, air and bone conduction pure tone audiometry, and direct measures of middle ear function (aural immittance tests) would be appropriate and necessary for any patient with a history or clinical evidence suggesting middle ear involvement.
AudiologyOnline: Why would I record OAEs on all patients – especially older people?
James W. Hall III: I don’t advise OAE measurement for all patients, but OAEs are certainly reasonable, appropriate, and medically necessary for a sizeable proportion of patients. OAEs are recommended in clinical practice guidelines for hearing assessment of infants and young children. In addition, close perusal of medical policies for health insurance companies often reveals guidelines for application of diagnostic OAEs (CPT code 92588) in older preschool children, children with delayed speech and language development, and patients of any age with a variety of risk factors for auditory dysfunction, among them tinnitus, acoustic trauma, noise exposure, sudden hearing loss, possible ototoxicity, evidence of false hearing loss, even abnormal auditory perception despite normal audiogram findings. On the other hand, OAEs are not typically “reasonable, appropriate, or necessary” for cognitively intact adult patients with established and stable sensory hearing loss.
AudiologyOnline: I get paid when I use 92557 – How will I “earn my keep” if I use other CPT codes?
James W. Hall III: Unfortunately, with reliance on CPT code 92557, you are not fairly paid for your time, effort, and expertise, nor adequately compensated for your costs of doing business such as overhead, equipment amortization, operating expenses, etc. Regardless of the charge you submit, your average Medicare payment with the 92557 code is likely to be about $38 … a paltry sum for the considerable clinic time (at least 25 to 30 minutes) you spend in performing air and bone conduction pure tone audiometry with masking, estimation of speech reception threshold, and assessment of word recognition in quiet. In contrast, according to the Medicare fee schedule you could expect minimum reimbursement of over $115 with a combination of CPT codes for diagnostic procedures that are reasonable and appropriate for many patients (e.g., 92552 for pure tone audiometry air only; 92556 for speech audiometry threshold with recognition; 92550 for tympanometry and acoustic reflex thresholds; 92588 for diagnostic DPOAEs (< 12 frequencies plus a report). In addition, overall test time would be comparable or even shorter for this patient-specific and chief-complaint driven assessment approach that includes relatively quick procedures, and procedures that are likely to yield information contributing to the prevention, diagnosis and management of hearing loss and related disorders (e.g., tinnitus or auditory processing deficits). In closing, based on my 40+ years of experience in providing patient services and directing audiology clinics, I’m certain that a departure from the routine and exclusive use of the 92557 CPT code is long overdue.