SPECIAL ALERT ON VESTIBULAR TESTING

The Academy is very concerned over the repeated inquiries it has been receiving regarding “income potentials” for vestibular testing that are being promoted by some companies, especially with respect to Medicare billing scenarios. Since these sales tactics have the potential of placing both members and non-members at significant risk of fraud and/or abuse charges, the Academy, in agreement with the Advisory Board, is posting this important notice in the “public” section of this web-site. Please note that the companies who are promoting these possibly fraudulent billing practices ARE NOT members of this Academy.

SPECIAL NOTE:  Due to the complexity of Medicare regulations, restrictions and potential practice liability, the Academy strongly recommends that practitioners who are providing these services have a valid Medicare Compliance Plan, properly instituted and maintained that includes a section on these services.  We also suggest that you have an independent review of your policies, documentation and billing procedures and that you maintain ongoing compliance monitoring to minimize your risk of unintentional errors in these areas of service.

ENG/VNG tests are tests of function. Their purpose is to determine if there is something wrong with the vestibular portion of the inner ear. If dizziness and balance problems are not caused by the inner ear, they might be caused by central nervous system pathologies, by other medical problems such as high or low blood pressure, or by psychological problems such as anxiety.

Studies have documented that ENG/VNG tests are more accurate than clinical examination in identifying inner ear disorders. Hearing pathway tests (audiometry, ABR, ECOG) are frequently conducted in conjunction with such vestibular tests.

As you may know, there have been recent clarifications from Medicare and the AMA on several of the codes that are employed for the balance testing procedures.  In light of these changes and following input and concurrence from our Advisory Board Specialists, the Academy has adopted the following positions on vestibular testing.  As always, the Academy stresses the need to establish reasonable medical necessity and proper documentation in support of vestibular testing, results and interpretations,  in order to support and justify reimbursement from any carrier and to protect against adverse post payment review decisions.

The following codes are routinely associated with the Vestibular Testing Procedures.

CPT/HCPCS Codes:

Several companies also recommend a post treatment or “follow-up” battery of ENG or VNG tests.  In the absence of continued symptoms and complaints from the patient, there is no medical necessity to repeat the testing and such billing is IMPROPER.  During treatment, when the clinical picture shows improvement, additional testing is also not indicated. 

Doctors of "specialty" may elect to perform post treatment analysis, provided it is properly documented and applicable, where the condition could still be of "clinical concern" due to the patient's ability to temporarily compensate for balance disorders through acclimatation of compensating but potentially harmful posture.

92770- Electro-oculography:  CPT 92270 (electro-oculography) deals with measuring eye movements other than in association with checking for the presence of nystagmus. As such, it is not considered an ENG/ VNG or audiometric code, but is instead considered to be a physician service code. It may only be billed when performed by a physician or when done by a qualified technician who is under the personal supervision of the billing physician and interpreted, with a clinical significance notation and report by the physician.  This code is “only normally associated” with:

362.55 Toxic maculopathy
362.75 Other dystrophies primarily involving the sensory retina
362.76 Dystrophies primarily involving the retinal pigment epithelium
362.77 Dystrophies primarily involving Bruch=s membrane

where such "physician interpretation" is medically necessary for proper assessment and management.

The following sections and regulations are routinely associated with coverage for vestibular testing under the Medicare system.

1. Title XVIII of the Social Security Act, section 1862(a)(7):  This section states that Medicare will not cover any services or procedures associated with routine physical checkups.
2. Title XVIII of the Social Security Act, section 1862(a)(1)(A):  This section allows coverage and payment for only those services that are considered reasonable and necessary.
3. Title XVIII of the Social Security Act, section 1833(e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.
4. Section 1861(II)2) of the Social Security Act: The diagnostic tests for which Medicare payment may be made to audiologists include hearing and balance assessment services.
5. MCM, section 2070.3. Otologic Evaluations: For Medicare coverage of audiologists performing hearing tests, the audiologists must be "qualified audiologists" as defined in the MCM. Also, this section states that hearing tests performed by audiologists are paid for on the basis of the Medicare physician fee schedule and not on a reasonable charge basis.

Indications and Limitations of Coverage and/or Medical Necessity:

1. Vestibular function tests and/or diagnostic audiometric tests are covered when testing is for the purpose of determining the appropriate medical or surgical treatment for disorders of the auditory, balance, and other neural systems.
2. When the medical factors required to determine the appropriate medical or surgical treatment are already known by the physician, or are not under consideration, and the diagnostic services are performed only to determine the need for or the appropriate type of hearing aid, the services are excluded from Medicare coverage whether performed by a physician or non-physician.  In other words, they are NOT medically necessary

Rule:  If a diagnostic test will not provide sufficient information to either change the diagnosis or significantly alter the plan of treatment for the patient, it is not medically significant or necessary.

3. For conductive hearing loss, hearing should be retested after medical or surgical treatment. For sensorineural hearing loss, the audiologist or physician will recommend when repeat testing should be done. Since hearing may change or fluctuate, it is important to detect this as early as possible to prevent further loss and to obtain medical treatment, if needed.
4. Screening evaluation or testing for hearing aid evaluation are specifically excluded.

Codes 92541, 92542, 92543, 92544, 92545, 92546 (92700) and 92547 are payable globally when done in place of service: office (11), state or local public health clinic (71), and community hearing and speech centers (99).

 The Academy Board of Directors appreciates the continued dedication and input of the members of our advisory board and the analysis and clarifications offered by the MedCorp Compliance Network.