The content in the following Q&A was compiled in collaboration with the Academy of Doctors of Audiology (ADA), the American Academy of Audiology (AAA), and the American Speech-Language-Hearing Association (ASHA), and is supported by the Academy of Rehabilitative Audiology (ARA), the Directors of Speech and Hearing Programs in State Health and Welfare Agencies (DSHPSHWA), and the Educational Audiology Association (EAA).
Billing for pediatric audiology services can be unclear and vary from payer to payer. The guidance below includes a review of both diagnosis and procedure coding. Procedure code guidance is based on the American Medical Association’s Current Procedural Terminology (CPT®) coding definitions. However, Medicaid and private payers may elect to include, omit, or further define codes for billing the benefits they allow. Always check with your primary payer regarding appropriate billing and coding guidelines.
There is significant variability in payer policies regarding reporting a normal examination following a failed newborn hearing screening. Please confirm with your payer regarding diagnosis coding requirements for newborn hearing re-screening.
The standardization of procedure and diagnosis code sets under the Health Insurance Portability and Accountability Act (HIPAA) has resulted in more payers acknowledging the supplementary classification code "Encounter for Hearing Examination Following Failed Hearing Screening" as a primary diagnosis code for newborn hearing follow-up testing. The ICD-10-CM code is Z01.110 (Encounter for hearing examination following failed hearing screening).
Some state programs and payers may require an ICD-10-CM diagnosis code such as "Unspecified Hearing Loss", even when test results are normal
See also: Coding Normal Results
92579 (VRA) and 92582 (CPA) are codes that describe specific, independent pediatric test procedures. These codes are currently valued as stand-alone procedure codes and are not "add-on" or modifier codes. Generally, these codes should not be used in addition to pure tone audiometry, air only (92552) or air and bone donduction audiometry (92553) to indicate a method of testing.
92579 (VRA) and 92582 (CPA) are differentiated by the method of response reinforcement used and the types of stimuli that are considered part of the procedure. These codes are historical codes and currently do not have detailed code descriptions. Payers have relied on traditional practice standards that were available at the time the codes were last valued. Historically, descriptions of VRA test procedures included both speech and tonal stimuli as part of the test protocol. In contrast, CPA test protocols included tonal stimuli but did not include speech stimuli.
If CPA (92582) testing is completed and speech measures are performed as part of the evaluation, then a code that best describes the speech measure, such as speech threshold audiometry (92555), select picture audiometry (92583), or speech audiometry threshold with speech recognition (92556), can also be reported.
In this case, it would still be appropriate to report the VRA code (92579) as it best reflects the technique and equipment that has been utilized to conduct the assessment. Since the VRA and CPA (92582) codes cannot be billed in addition to pure-tone air or bone conduction threshold codes, you should choose the code that best aligns with your clinical assessment.
The issue of limited or no audiologic test results is a complicated one; the codes that you select should accurately reflect the procedures, techniques, and effort that were used, not specifically the number of responses that were obtained.
A child may require frequent reconditioning or test reinstruction, yet limited audiologic information is obtained. In this case the audiologist has used considerable effort, various procedures, and/or different reinforcement techniques to obtain those limited results. This would not be considered a reduced service.
Documentation of the test session should include the efforts made to obtain test results; some clinicians may document a time notation in the patient’s medical record as an estimate of the time and effort involved when limited audiologic information is obtained.
There may be a number of reasons why no audiologic results are obtained. However, in a situation where a child is completely uncooperative with any test procedure, the audiologist has a choice of cancelling the appointment altogether or using a reduced service modifier (-52) to indicate that the entire protocol associated with the diagnostic procedure was not completed.
New CPT codes were created in 2010, at the request of the Centers for Medicare and Medicaid Services (CMS), to report middle ear function tests that were frequently performed together on the same date of service. Four distinct codes are now available:
The individual code for acoustic reflex decay testing (92569) was deleted at the time of the 2010 code changes.
If acoustic reflex threshold testing or acoustic reflex threshold testing and acoustic reflex decay testing are performed on the same date of service as tympanometry, you must report the bundled code that describes what has been performed. You may not report tympanometry (92567) and acoustic reflex threshold testing (92568) separately on the same date of service.
CPT has defined acoustic reflex threshold testing (92568 and 92550) as including both ipsilateral and contralateral acoustic reflex threshold measurements. There is not a CPT code available for acoustic reflex screening. Only the tympanometry code (92567) would be allowed in this instance.
New methods of assessing middle ear function are now available in clinical test equipment. Although these advanced middle ear test methods are becoming accepted as part of a clinical test battery, there are no current CPT codes for these tests.
The tympanometry-only code (92567) should be used if wideband reflectance or multi-frequency tympanometry tests are completed. The code is a session-based code, meaning that 92567 can only be billed one time per day, even if standard and multi-frequency tympanometry as well as wideband reflectance testing are all completed on the same day.
An extended service modifier (-22) could be considered when multi-frequency tympanometry and wideband reflectance testing are completed on the same day. Detailed documentation of the justification for the extended service should be included in the patient’s medical record.
There are three OAE codes that clearly describe the differences between screening OAE and limited versus comprehensive OAE evaluation. The OAE codes assume that testing is completed in both ears. Append modifier -52 (reduced service) to the CPT code for unilateral testing.
The OAE screening code (92558) should be billed when only an overall Pass/Fail result is obtained and no other interpretation is performed or reported.
The OAE limited evaluation code (92587) should be used when the purpose of the test is to evaluate hearing status. 92587 specifies that three (3) to six (6) Distortion Product (DPOAE) frequencies should be evaluated per ear. Transient Evoked OAE testing (TEOAE) is included in this code.
The OAE comprehensive evaluation code (92588) should be used when the purpose of the test is to evaluate outer hair cell function or to perform cochlear mapping for purposes such as ototoxic monitoring or tinnitus evaluation. 92588 specifies that 12 or more distortion product OAE frequencies should be evaluated per ear.
For more information regarding the correct billing of OAEs, visit any of the following sites for CPT coding guidance:
Report ABR screening and testing one of four CPT codes describing auditory evoked potential (AEP) testing, as follows. The AEP testing codes assume that testing is completed in both ears. Append modifier -52 (reduced service) to the CPT code for unilateral testing.
92651 describes nonautomated follow-up electrophysiologic testing to rule out significant hearing loss, including auditory neuropathy/auditory dyssynchrony, or to verify the need for additional threshold testing. Testing includes obtaining responses to broadband-evoked auditory brainstem responses (ABRs) using click stimuli at moderate-to-high and low stimulus levels. Don't report 92651 in conjunction with 92652 or 92653.
92652 describes extensive electrophysiologic estimation of behavioral hearing thresholds using broadband and/or frequency-specific stimuli at multiple levels and frequencies. 92652 can also include testing with high level stimuli and rarefaction/condensation runs to confirm auditory neuropathy/auditory dyssynchrony. 92652 reflects comprehensive AEP testing for the purpose of quantifying type and degree of hearing loss. Don't report 92652 in conjunction with 92651 or 92653.
92653 describes testing to evaluate neural integrity only, without defining threshold. Report this code when the purpose of testing is to identify brainstem or auditory nerve function. 92653 is a less extensive test than 92652 and the basic elements of 92653 are already included in 92651 or 92652 when they are performed to identify and quantify hearing impairment. Don't report 92653 in conjunction with 92651 or 92652.
ASSR is considered to be a type of auditory evoked potential (AEP) test and currently does not have a specific CPT code. The AEP code for thresthold estimation (92652) is the most appropriate code for billing ASSR at this time.
92652 is a session-based code; this means that it can only be billed one time per day, even if both ABR and ASSR testing are completed on that day.
As discussed above, an extended service modifier (-22) could be considered when both ABR and ASSR are completed on the same day, but only if the time and work to perform AEP testing is substantially greater than usual. Detailed documentation of the justification for the extended service should be included in the patient’s medical record. Claims with modifier -22 may also be stopped for manual review.
The -33 modifier was designed to allow providers a means to identify preventative services such as newborn hearing screening or re-screening procedures. In some cases these services are mandated by the Patient Protection and Affordable Care Act (ACA) and should not be subject to a patient cost share (i.e., co-pay, deductible, etc.).
As the use of modifiers varies widely between payers, it is recommended that you consult your payers to determine the recommended utilization for the -33 modifier for newborn hearing screening or re-screening procedures.
These codes require that the primary evaluation codes (92620 or 92626), which include the first 60 minutes of evaluation time, be billed before the additional 15-minute codes (92621 or 92627).
For example, first bill 92620 (Evaluation of central auditory function, with report; initial 60 minutes), then 92621 for each additional 15 minutes of evaluation time.
When using time-based codes, the audiologist is required to properly document evaluation start and end times in the patient’s medical record.
See also: The Right Time for Billing Codes
Note: The use of 92626 and 92627 as described below is specifically for pediatric applications. Please see other professional guidance for the correct use of this code when evaluating Medicare-eligible recipients.
92626 and 92627 are codes that reflect the evaluation of a child’s ability to use residual hearing with an auditory implant, such as a cochlear implant.
The evaluation process focuses on a battery of procedures designed to examine—in much greater detail than a standard audiogram—the magnitude of speech understanding abilities with and without amplification or cochlear implant devices, the suitability and usability of various assistive listening devices, and the appropriateness of alternative alerting devices.
92626 and 92627 are timed codes on the basis that there will be a battery of standardized tests used to make the assessment. The number of tests included in the evaluation will vary according to the age and capability of the child. Whereas a young child may be limited in the number of tests that can be completed, an older child will be able to complete a greater number and variety of tests.
Another purpose of the evaluation is to determine whether the child could be an auditory implant candidate and to document progress in speech understanding post-implant. Evaluation results can be used as a diagnostic foundation that leads to a customized intervention program for that child.
92626 and 92627 cannot be used as counseling codes or services unrelated to pre- or post-implant auditory function evaluation.
If I perform an evaluation for (central) auditory processing (92620) and include filtered speech (92571), staggered spondaic words (92572), and synthetic sentence identification (92576), can I bill the specific test codes in addition to the general auditory processing evaluation code?
Check with your payer. There is a National Correct Coding Initiative (NCCI) edit that prohibits billing 92571, 92572, and 92576 on the same day as 92620 for Medicare beneficiaries. Many Medicaid and private payers utilize NCCI edits in their coding guidelines.
The CI codes (92601-92604) are session-based codes and only one unit (code) should be billed per day.
CI codes 92601 (diagnostic analysis of cochlear implant, younger than 7 years of age; with programming) and 92603 (diagnostic analysis of cochlear implant, age 7 years or older; with programming) describe the post-operative analysis and fitting, connection to the implant, and initial programming of the stimulator.
Codes 92602 (younger than 7 years of age, subsequent re-programming) and 92604 (7 years or older, subsequent re-programming) are used for subsequent sessions to include measurement, adjustments, and re-programming.
Reimbursement for binaural CI programming varies between payers. Please consult your payer(s) to determine if CI programming codes (92601-92604) are considered unilateral or single device codes.
Some payers may accept two line items of the same code with –RT or –LT ear modifiers to designate which side was programmed.
Other payers may consider a binaural programming session as a same-day repeat procedure. In this case, a separate bill with the same date of service would be completed. The second CI programming code would be billed with a repeat procedure modifier added (-76: Repeat procedure by same provider; or -77: Repeat procedure by another provider).