This First Coast Billing and Coding Article for Local Coverage Determination (LCD) L33966 Vestibular Function Tests provides billing and coding guidance for frequency limitations as well as diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in the LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
Refer to the LCD for reasonable and necessary requirements and limitations.
The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in the LCD.
Coding Guidelines
For CPT code 92546 (Sinusoidal vertical axis rotational testing), Auto Head Rotation Tests, sometimes referred to as Active-Head Rotation Tests, should not be billed with this code.
The physician ordering the vestibular test must appear on the audiologist claim.
For procedure code 92537: Goggles are placed over the patient’s eyes and adjusted firmly on the patient’s face. Video cameras are positioned so that the pupils are in the field of the camera, and contrast and sensitivity are adjusted so that the pupil can be differentiated and tracked during testing. Caloric vestibular test is performed by irrigating the ear canal with either water or air for a period of 30 to 60 seconds and recording the movement response (nystagmus) for approximately two minutes following the irrigation. Sufficient time is given (Typically 5 minutes) before the opposite ear is irrigated. Based on standard practice, procedure code 92537 is intended to report a complete caloric vestibular testing procedure that includes bilateral performance of bithermal irrigation (ie, one warm and one cool irrigation for each each). Fewer irrigation procedures require a different method of reporting according to what was done. Three irrigations (ie, irrigation of both ears using monothermal irrigation of one ear and bithermal irrigation of the contralateral ear), code 92537 is reported with modifier 52 appended.
For procedure code 92538: Monothermal irrigation (ie; irrigation of both ears with either cool or warm irrigation) is reported once with procedure code 92538. If a single ear is irrigated with a single method of irrigation (cool or warm), procedure code 92538 is reported once with modifier 52 appended.
It is not expected to see 92540, 92541, 92542 or 92544, 92545 or 92546 billed more than once during a session.
Procedure codes 92540-952546 have a professional and technical component. It would be appropriate to bill a –26 and –TC modifier if necessary.
Do not report 92540 in conjunction with 92541, 92542, 92544 or 92545.
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
Documentation Requirements
- All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
- The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
- An order from the treating physician/nonphysician practitioner as required by CFR, Title 42, Volume 2, Chapter IV, Part 410.32(a) Ordering diagnostic tests.
- The services require a recording be obtained at the time the service is rendered. These recordings must be maintained in the patient’s medical record and be made available upon request. The procedure report by itself is not enough to show that the services being billed are medically reasonable and necessary. Documentation of the medical necessity of the service is typically found in the office note when the service is performed in an office setting or the physician's progress note(s) when the service is performed in a facility setting.
- The medical record must contain a detailed history and physical exam including a complete medication review. The medical record must support that other physiological/psychological, medication or other systemic reasons that could cause the balance problems were ruled out and that it is medically necessary to proceed with diagnostic testing of the vestibular system. The medical record must also contain the name and serial number of the equipment used to perform the vestibular tests.
Utilization Guidelines
In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.
Compliance with the provisions in LCD L33966, Vestibular Function Tests may be monitored and addressed through post payment data analysis and subsequent medical review audits.
