Otolaryngology Coding Alert

When otolaryngologists test patients with vertigo to determine the source of their dizziness, the examinations fall into two general categories: recorded (electronystagmography, or ENG) and non-recorded. Medicare will reimburse the former but not the latter. So increasingly, otolaryngologists either send patients to a vertigo center for recorded testing, or if they have the equipment in their own offices, perform the test there.

Patients complaining of dizziness are often referred by their primary care physicians, and may pose a diagnostic dilemma for otolaryngologists, because vertigo can occur due to a variety of factors originating in the inner ear or nervous system, says Edward F. Babb, MD, CPC, an otolaryngologist and coding consultant in NJ. We are attempting to determine the etiology (cause) of the vertigo, he says. By taking the patients history, positional testing and caloric testingstimulation of the inner ear via a thermal effect by warm and cold applications of either air or water, you may be able to say the problem is inner ear.

The procedures Dr. Babb describes are known as vestibular function tests. Before the advent of ENG, otolaryngologists performed these tests without electrical recording and billed for the exam as follows:

92531: spontaneous nystagmus, including gaze

92532: positional nystagmus

92533: caloric vestibular test, each irrigation (binaural,
bithermal stimulation constitutes four tests)

Because the caloric tests typically involve stimulating both ears with warm and cold water or air, code 92533 would take four units, two for left and right ear and two for warm and cold water or air.

Note: Although Medicare no longer pays for these tests, some private payers still do, so it is important to check with your carrier before performing non-recorded vestibular functions tests.

The fallout from Medicares decision to no longer reimburse non-recorded tests impacts on otolaryngologists performing the Dix-Hallpike test, a non-invasive positional procedure used to accurately determine if a patient has benign paroxysmal positioning vertigo, or BPPV. In this disorder, some of the very small crystals of calcium carbonate located in the inner ear are dislodged and float down into one of the three canals of the inner ear. The crystals are trapped in the canal, and when the person moves in certain ways, the crystals move and give the person the sensation of spinning, i.e., vertigo. However, the Dix-Hallpike test is not a Medicare-reimbursed procedure, and neither is the procedure most often used to treat BPPV, known as the canalith repositioning procedure. This technique is used to clear the crystal out of the canal and deposit it back into the part of the inner ear where it belongs.

In the past, the canalith repositioning procedure could be billed using code 97112 (neuromuscular reeducation of movement, balance, coordination, kinesthetic [...]