Medicare Compliance & Reimbursement

In January, you finally got a code to describe the Epley maneuver, a simple but time-consuming treatment for a type of dizziness. But now you're having even more trouble getting paid for the work.

The Epley maneuver treats a form of vertigo (386.11, Benign paroxysmal positional vertigo) that is caused by small calcium carbonate stones that have moved from the vestibule of the inner ear into the semicircular canals, where your sense of balance rests. The stones stimulate nerves and cause a spinning sensation, nausea, and unsteadiness.

During the Epley procedure, the patient's head is maneuvered so the calcium crystals roll out of the sensing tube and into another inner chamber of the ear, from which the body can absorb them.

The way it was: For years, CPT didn't have a dedicated code for the procedure, but at least some coders had success using 92700 (Unlisted otorhinolaryngological service or procedure). "Prior to October, our office had not had any problems getting paid for the Epley," says Candice Ruffing, CPC, CENTC, who codes for Drs. Berghash, Lanza & Zeiders in Port St. Lucie, Fla.

"In field 19A [of the CMS 1500 form] we would enter the description 'canalith repositioning maneuver,'" Ruffing says.

And now: The AMA brought out a new code 95992 (Canalith repositioning procedure[s] [e.g., Epley maneuver, Semont maneuver], per day) to describe the Epley.

Trouble is, Medicare denies payment for it.

"Since CPT assigned 95992 -- our office has not gotten paid for one," Ruffing says.

Why aren't you getting paid for the new Epley code?

Coders are running into two problems.

Problem 1: In Medicare's fee schedule database, 95992's status code is "B," which, according to CMS, means it is "always bundled into payment for other services not specified. There will be no payment amount for these codes, and no separate payment is made."

That means 95992 is automatically bundled with any other service -- or with no service at all. "They are bundling it against nothing. This is what has us so confused," says Rachel Poe, who works for a Texas company that bills for an ENT clinic. "I have always had a devil of a time getting Epleys paid, but now it is impossible."

You can try to bill 95992 with another service with other payers. "We ran a report today and it looks as if some commercial insurances are paying for this code,"

Poe confirms. "I don't seem to be having any problems with them."

If a commercial insurer does pay, do not be surprised if, in the future, a recovery company asks for the money back because it is a "bundled code."

Problem 2: For years, audiologists have performed Epley maneuvers on patients who experience dizziness.

With the new code, under Medicare, audiologists can't get paid for the Epley procedure. Period.

Payers have denied Ruffing's 95992 claims "for not being performed by a qualified provider," she says. Sure enough, an audiologist has been doing the Epley maneuvers in her office.

Medicare limits audiologists' scope of practice to diagnostics.

But before Oct. 1, you billed an audiologist's services incident-to the physician under the physician's NPI.

Now that audiologists bill under their own NPIs, their involvement with a patient is clear to the payer.

If the local carrier (Medicare or non-Medicare) LCD has specifically stated that Epley is part of E/M and should not be reported separately, then the practice should not do so, says Linda Ayers, MHCM, CAE, senior director for health policy at the American Academy of Otolaryngology Head and Neck Surgery.

"If there is not an LCD, then I'd say to report it or write a query to the carrier requesting written verification of how to report the two services."

Ayers compares the situation to that of consultation services.

"Unless the carrier is very clear, CPT rules should apply," she says. If your practice needs to track Epleys but must count them as part of E/M, it should create an internal code with a value of $0.