Local Coverage Determination (LCD): Vestibular and Audiologic Function Studies (L32767)

Transcription

1 Lcal Cverage Determinatin (LCD): Vestibular and Audilgic Functin Studies (L32767) Cntractr Infrmatin Cntractr Name Nvitas Slutins, Inc. LCD Infrmatin Dcument Infrmatin LCD ID L32767 LCD Title Vestibular and Audilgic Functin Studies AMA CPT/ADA CDT Cpyright Statement CPT nly cpyright American Medical Assciatin. All Rights Reserved. CPT is a registered trademark f the American Medical Assciatin. Applicable FARS/DFARS Apply t Gvernment Use. Fee schedules, relative value units, cnversin factrs and/r related cmpnents are nt assigned by the AMA, are nt part f CPT, and the AMA is nt recmmending their use. The AMA des nt directly r indirectly practice medicine r dispense medical services. The AMA assumes n liability fr data cntained r nt cntained herein. The Cde n Dental Prcedures and Nmenclature (Cde) is published in Current Dental Terminlgy (CDT). Cpyright American Dental Assciatin. All rights reserved. CDT and CDT-2010 are trademarks f the American Dental Assciatin. Original Effective Date Fr services perfrmed n r after 08/13/2012 Revisin Effective Date Fr services perfrmed n r after 07/22/2013 Revisin Ending Date N/A Retirement Date N/A Ntice Perid Start Date N/A Ntice Perid End Date N/A

2 CMS Natinal Cverage Plicy This LCD supplements but des nt replace, mdify r supersede existing Medicare applicable Natinal Cverage Determinatin(s) r payment plicy rules and regulatins fr vestibular and audilgy services. Federal statute and subsequent Medicare regulatins regarding prvisin and payment fr medical services are lengthy. They are nt repeated in this LCD. Neither Medicare payment plicy rules nr this LCD replace, mdify r supersede applicable state statutes regarding medical practice r ther health practice prfessins acts, definitins and/r scpes f practice. All prviders wh reprt services fr Medicare payment must fully understand and fllw all existing laws, regulatins and rules fr Medicare payment fr vestibular and audilgy services and must prperly submit nly valid claims fr them. Please review and understand them and apply the medical necessity prvisins in the plicy within the cntext f the manual rules. Relevant CMS manual instructins and plicies regarding vestibular and audilgy services are fund in the fllwing Internet-Only Manuals (IOMs) published n the CMS Web site: Medicare Benefit Plicy Manual Pub , Chapter 15, Sectins 80.3 and Medicare Natinal Cverage Determinatins Manual Pub Medicare Claims Prcessing Manual Pub : Chapter 12, Sectin Chapter 13. Crrect Cding Initiative Medicare Cntractr Beneficiary and Prvider Cmmunicatins Manual Pub , Chapter 5. Scial Security Act (Title XVIII) Standard References, Sectins: 1861(II)(2) Payments t Audilgists. 1861(II)(3)(B) Qualificatins f Audilgists. 1862(a)(1)(A) Medically Reasnable & Necessary. 1862(a)(1)(D) Investigatinal r Experimental. 1862(a)(7) Screening (Rutine Physical Checkups). 1833(e) Incmplete Claim. Cverage Guidance Cverage Indicatins, Limitatins, and/r Medical Necessity Ntice: It is nt apprpriate t bill Medicare fr services that are nt cvered (as described by this entire LCD) as if they are cvered. When billing fr nn-cvered services, use the

3 apprpriate mdifier. Vestibular tests are tests f functin. Their purpse is t determine if there is smething wrng with the vestibular prtin f the inner ear. If dizziness is nt caused by the inner ear, it might be caused by the brain, medical disrders such as lw bld pressure r psychlgical prblems such as anxiety. Studies have dcumented that vestibular tests are mre accurate than clinical examinatin in identifying inner ear disrders. Hearing pathway tests (audimetry, Auditry Brainstem Respnse (ABR), Electrcchlegraphy (ECG)) can als be used fr the same purpse and are frequently cmbined with vestibular tests. Diagnstic tlgic evaluatin services are perfrmed t detect presence r absence f a hearing deficit and t identify the factrs respnsible fr the deficit. The assessment f a deficit invlves bth physical and physilgical measurements fr apprpriate diagnsis and referral. Accurate assessment f hearing (audimetry) is vital t the diagnstic evaluatin f patients with suspected tlgic disrders fr the determinatin f the underlying prcess, as well as in the planning f rehabilitatin f hearing lss. Originally, audimetry was limited t the psychphysical measurement f the sensatin f hearing; thus, patient cperatin was essential. Hwever, ther tests have been develped ver the years that permit mre bjective assessment f hearing even in infants, small children, malingerers and hysterics. Mst humans hear sunds in the range f 20 t 20,000 Hz. Sensitivity varies as a functin f frequency, with sunds in the middle frequencies being heard best. The ability t hear higher frequencies declines with age. Basic Audimetry: Adequate testing requires an audimeter (device fr presenting sunds t the patient at precisely cntrlled intensity), a cntrlled acustic envirnment that meets American Natinal Standards Institute (ANSI) specificatins, a cmpetent audilgist and a cperative patient. The standard testing battery may vary depending n purpse. Pure Tne Audimetry, Speech Audimetry and Immittance Audimetry Pure Tne Audigram: This is a graphic plt f the patient s threshlds f audimetry sensitivity fr pure tne (sine wave) stimuli. Threshld hearing levels are indicated fr each frequency tested. By cnventin, nrmal hearing levels are shwn at the tp f a graph; a decrease in hearing sensitivity is indicated by larger values f hearing level. Hearing level is pltted n a lgarithmic decibel scale. Sunds are tested with presentatin by air cnductin (earphnes) as well as bne cnductin (skull vibratr). An air bne gap indicates a cnductive cmpnent f hearing lss. A decrease in threshld sensitivity by bne cnductin reflects a sensry r neural lss.

4 Speech Audimetry: These tests utilize spken wrds and sentences rather than pure tnes. Tests are designed t assess sensitivity (threshld) r understanding (intelligibility). Threshld The level at which the patient can crrectly repeat 50 percent f test materials: Phneme-Balanced (PB) wrds, synthetic sentences, etc. Intelligibility By cnventin, the percentage f wrds r sentences a patient can crrectly repeat when presented at suprathreshld levels. Prvides infrmatin abut hearing handicap. Prblem may be wrse than indicated by Pure Tne Average (PTA) fr the speech frequencies. Useful t determine candidacy fr hearing aid. Very pr results, ut f prprtin t PTA, suggest prbable retrcchlear cause f hearing lss. Immittance Audimetry: These hearing tests utilize an electracustic immittance bridge. This device is designed t quantify the impedance (resistance t mvement) f the cnductive mechanism f the ear by buncing a prbe tne ff the tympanic membrane and measuring the prprtin f reflected sund. Impedance testing can measure either the impedance r admittance (the American Speech-Language-Hearing Assciatin term that encmpasses bth is immittance ). Typically, tday s equipment measures admittance. The purpse f the test is t assess middle ear integrity. Maximal reflectin f sund ccurs when the mechanism is very stiff, while a cmpliant system transmits mre sund and reflects less. There are tw principal applicatins f this device: Tympanmetry: A tympangram is a graphic representatin f the relatinship f external auditry canal air pressure t impedance; the latter is usually reprted in terms f tne f its derivatives, cmpliance in arbitrary units. Pressure in the external auditry canal is varied frm -200 dapa thrugh +200 dapa while mnitring impedance. Impedance is the lwest (maximal cmpliance) when pressure in the canal equals pressure in the middle ear. Ears can be classified int three basic grups (Type A, Type B and Type C) n the basis f the cnfiguratin f the tympangram. Acustic Reflex (AR): Cntractin f the stapedius muscle ccurs with lud sunds, prducing a measurable change in cmpliance. Diagnstic Audimetry: Cnsists f a battery f tests intended t determine the site f lesin in

5 patients with tlgic r neurlgic disrders. The cnstellatin f tests varies accrding t the available test battery and prvisinal diagnsis. Immittance audimetry: See abve. PI-PB functins: Speech discriminatin is pltted as a functin f sund intensity. Nrmally, discriminatin imprves with intensity up t a maximal level, then plateaus. In eighth nerve disrders, discriminatin ften declines dramatically as intensity increases abve the level yielding maximum perfrmances. Bekesy Audimetry: This test has a significant histrical interest in the develpment f assessment f hearing; hwever, tday it is used predminantly nly in industrial and military hearing screening situatins. Patient traces his wn auditry threshld by means f a self-recrding audimeter. Tracings are btained fr pulsed as well as cntinuus tnes. The relatinship between the tw categries can be categrized int diagnstic patterns. Tne Decay Tests: Abnrmal adaptatin t a cntinuus tne is seen in retrcchlear lesins. Stenger Test: Perfrmed t detect malingering f unilateral lss. If sund is presented t bth ears, patient will deny hearing in the ear with the feigned lss. If sund is presented t the gd ear at a suprathreshld level, simultaneus t a luder sund in the questinable ear, a malingerer will lcalize the sund t his bad ear, and therefre deny hearing anything at all. Evked ABRs: Scalp electrdes measure electrical activity in respnse t sund clicks. The respnse is quite small in relatin t ther nging brain activity, but by presenting a large number f clicks and averaging the respnses by cmputer, unrelated events can be canceled ut. This is useful fr dcumenting hearing in uncperative r unrespnsive patients. The disadvantage is that it tests mainly the 1,000 4,000 Hertz frequency range f hearing and is a pr indicatr f the verall auditry functin. An abnrmal ABR is seen in eighth nerve r brainstem lesins. ECG: Electrical activity is measured frm the prmntry and respnses t a large number f clicks are averaged. These will be abnrmal in eighth cranial nerve lesins and certain cchlear disrders. Audilgist s Services Audilgical diagnstic testing refers t tests f the audilgical and vestibular systems, e.g., hearing, balance, auditry prcessing, tinnitus and diagnstic prgramming f certain prsthetic devices, perfrmed by qualified audilgists. Audilgical tests require the skills f an audilgist and shall be furnished by qualified audilgists r, in states where it is allwed by state and lcal laws, by a physician r Nn- Physician Practitiner (NPP). Medicare is nt authrized t pay fr these services when perfrmed by audilgical aides, assistants, technicians r thers wh d nt meet the qualificatins belw. In cases where it is nt clear, the Medicare cntractr shall determine

6 whether a service is an audilgical service that requires the skills f an audilgist and whether the qualificatins fr an audilgist have been met. Diagnstic testing, including hearing and balance assessment services, perfrmed by a qualified audilgist is cvered as ther diagnstic tests under Sectin 1861(s)(3) f the Scial Security Act (the Act). This type f testing can be allwed when a physician rders the tests t btain infrmatin as part f his diagnstic evaluatin r t determine the apprpriate medical r surgical treatment f a hearing deficit r related medical prblem. Payment fr diagnstic services perfrmed by a qualified audilgist is determined by the reasn the tests were perfrmed, rather than the diagnsis r the patient s cnditin. The practice f the prfessin f audilgy means the applicatin f principles, methds and prcedures f measurement, testing, evaluatin, cnsultatin, cunseling, instructin and rehabilitatin related t hearing, its disrders and related cmmunicatin and impairments fr the purpse f nn-medical diagnsis, preventin, identificatin, ameliratin r mdificatin f such disrders and cnditins in individuals and/r grups f individuals. As prvided in Sectin 1861(II)(3) f the Act, a qualified audilgist is an individual with a master s degree r dctral degree in audilgy and wh has a valid license issued by the state in which the services are rendered. In additin t the abve qualificatin criteria, the fllwing requirements must als be met: The testing is rdered by a physician t btain additinal infrmatin t evaluate the need fr r apprpriate type f medical r surgical treatment fr a hearing deficit r related medical prblem even if the nly utcme is the prescriptin f a hearing aid. The name f the physician rdering the testing is reprted n the audilgist s claim. Fr example, if a beneficiary underges diagnstic testing perfrmed by an audilgist withut a physician s referral, these tests are nt cvered even if the audilgist discvers a pathlgic cnditin. The entity billing fr the audilgist s services may accept assignment under the usual prcedure r, if nt accepting assignment, may charge the patient and submit a nn-assigned claim n his behalf. Individuals Wh Prvide Audilgical Tests: Sme diagnstic audilgical tests require, fr bth the technical and prfessinal cmpnents, the skills f an audilgist t perfrm the test and interpret nt nly the data utput but als the manner f the patient s respnse t the test. These tests must be persnally furnished by an audilgist r a physician. The skills f an audilgist required when furnishing the rdered diagnstic tests invlve skilled judgment r assessment including but nt limited t:

7 Interpretatin, cmparisn r cnsideratin f the anatmical r physilgical implicatins f test results r patient respnsiveness t stimuli during the test. Mdificatin f the stimulus based n respnses btained during the test. Chices fr subsequent presentatins f stimuli r tests in a battery f tests. Tests related t implantatin f auditry prsthetic devices, central auditry prcessing r cntralateral masking. Tests designed t identify central auditry prcessing disrders, tinnitus r nn-rganic hearing lss. The technical cmpnents f certain audilgical diagnstic tests, i.e., tympanmetry ( 92567) and vestibular functin tests (e.g., 92541) that d nt require the skills f an audilgist may be perfrmed by a qualified technician r by an audilgist, physician r NPP acting within his/her scpe f practice. If perfrmed by a technician, the service must be prvided under the direct supervisin (42 CFR (3)) f a physician r NPP wh is respnsible fr all clinical judgment and fr the apprpriate prvisin f the service. The physician r NPP bills the directly supervised service as a diagnstic test. Indicatins Vestibular functin tests and/r diagnstic audimetric tests are cvered when testing is fr the purpse f determining the apprpriate medical r surgical treatment fr disrders f auditry, balance and ther neural systems. Fr cnductive hearing lss, hearing shuld be retested after medical r surgical treatment r bservatin. Fr sensrineural hearing lss, the audilgist r physician will recmmend when reasnable and necessary repeat testing shuld be dne. Since hearing may change r fluctuate, it is imprtant t detect this as early as pssible t prevent further lss and t btain medical treatment if needed. Billing fr any testing assumes that the prvider has a reasnable expectatin that the patient will require medical r surgical treatment. Repeat testing fr age-related hearing lss either as a fllw-up r t screen fr hearing aids is nn-cvered. Audilgic testing (CPT cdes 92553, and 92568) may be perfrmed fr patients n cntinuing (current) lng-term (mre than 14 days) use f antibitics knwn t be ttxic, such as streptmycin and aminglycsides. If a physician refers a beneficiary t an audilgist fr evaluatin f signs and symptms assciated with hearing lss r ear injury, the audilgist s diagnstic services are cvered, even if the nly utcme is the prescriptin f a hearing aid. Services by an independent audilgist t beneficiaries in a Part B Skilled Nursing Facility (SNF) stay (beneficiaries wh have exhausted their Part A-cvered SNF stay) are payable under Part B. The prvider shuld bill these services directly t the Part B carrier. Diagnstic analysis f cchlear r brain stem implant and prgramming are audilgy diagnstic services cvered under the ther diagnstic test benefit. Audilgical

8 diagnstic tests befre and peridically after implantatin f auditry prsthetic devices are cvered services. Limitatins Screening evaluatin r testing fr hearing aid evaluatin is specifically excluded. This exclusin des nt apply t the evaluatin fr the auditry sseintegrated device, knwn as the Bne-Anchred Hearing Aid (BAHA) device. Services are excluded under Sectin 1862(a)(7) f the Act when: The diagnstic infrmatin required t determine the apprpriate medical r surgical treatment is already knwn t the physician r is nt under cnsideratin. The diagnstic services are perfrmed nly t determine the need fr the apprpriate type f hearing aid. Nte: The abve services are excluded frm Medicare cverage whether perfrmed by a physician r Nn-Physician Practitiner (NPP). If a beneficiary underges diagnstic testing perfrmed by an audilgist withut a physician s referral, these tests are nt cvered even if the audilgist discvers a pathlgic cnditin. CPT cde is cnsidered part f the speech-language pathlgy services that must be cnslidated when the patient is in either a Part A SNF stay r Part B SNF stay. Allwed unit limitatins (nce per prvider, per discipline, per date f service, per patient) by discipline fr CPT cde are described in the Utilizatin Guidelines sectin belw. Services dcumented as audilgical services when furnished thrugh use f cmputeradministered tests that d nt require the skills f an audilgist are nt cvered. Audilgical services billed as incident t the service f a physician r NPP r as services incident t an audilgist s services are nt cvered. When a qualified physician r NPP rders a specific audilgical test using the CPT descriptr fr the test, nly that test may be prvided n that rder. Further rders are necessary if the rdered test indicates that ther tests are necessary t evaluate, fr example, the type r cause f the cnditin. Orders fr specific tests are required fr technicians. Hwever, when the qualified physician r NPP rders diagnstic audilgical tests by an audilgist withut naming specific tests, the audilgist may select the apprpriate battery f tests.

9 These services are cvered by Medicare when prvided in the lcatins described in the Bill Type/Revenue Cdes r Place f Service sectins belw. Ntice: This LCD impses diagnsis limitatins that supprt diagnsis t prcedure cde autmated denials. Hwever, services perfrmed fr any given diagnsis must meet all f the indicatins and limitatins stated in this plicy, the general requirements fr Medical Necessity as stated in CMS payment plicy manuals, any and all existing CMS natinal cverage determinatin, and all Medicare payment rules. As published in CMS IOM , Sectin , in rder t be cvered under Medicare, a service shall be reasnable and necessary. When apprpriate, cntractrs shall describe the circumstances under which the prpsed LCD fr the service is cnsidered reasnable and necessary under 1862(a)(1)(A). Cntractrs shall cnsider a service t be reasnable and necessary if the cntractr determines that the service is: Safe and effective. Nt experimental r investigatinal (exceptin: rutine csts f qualifying clinical trial services with dates f service n r after September 19, 2000, that meet the requirements f the Clinical Trials NCD are cnsidered reasnable and necessary). Apprpriate, including the duratin and frequency that is cnsidered apprpriate fr the service, in terms f whether it is: Furnished in accrdance with accepted standards f medical practice fr the diagnsis r treatment f the patient's cnditin r t imprve the functin f a malfrmed bdy member. Furnished in a setting apprpriate t the patient's medical needs and cnditin. Ordered and furnished by qualified persnnel. One that meets, but des nt exceed, the patient's medical needs. At least as beneficial as an existing and available medically apprpriate alternative. Training and Cmpetency Requirements Vestibular and audilgic testing reprted fr Medicare payment must be perfrmed by and/r directly supervised by persns pssessing apprpriate knwledge and technical expertise f vestibular and hearing. Therefre, Medicare will allw payment fr the fllwing:

10 Physicians wh have cmpleted training requirements sufficient t satisfy the relevant ABMS/AOA bards fr certificatin in tlarynglgy, neurlgy, neurlgic surgery, physical medicine and rehabilitatin, and phthalmlgy. Independent Diagnstic Testing Facilities (IDTFs) when services are perfrmed r directly supervised by physicians wh have cmpleted training requirements sufficient t satisfy the relevant ABMS/AOA bards fr certificatin in tlarynglgy, neurlgy, neurlgic surgery, physical medicine and rehabilitatin, and phthalmlgy. Upn medical review, ther physicians and qualified nn-physician practitiners wh demnstrate cmmensurate training as physician training requirements abve. Audilgists licensed by the state(s) in which they practice and are perfrming services within their state licensure s scpe f practice and Medicare regulatin Nte: Payment fr technical cmpnents f Technical Cmpnent (TC)/Prfessinal Cmpnent (PC) services (when the PC is perfrmed by an apprpriate prfessinal) and fr technical-nly services are allwed t hspitals. Cding Infrmatin Bill Type Cdes: Cntractrs may specify Bill Types t help prviders identify thse Bill Types typically used t reprt this service. Absence f a Bill Type des nt guarantee that the plicy des nt apply t that Bill Type. Cmplete absence f all Bill Types indicates that cverage is nt influenced by Bill Type and the plicy shuld be assumed t apply equally t all claims. 012x Hspital Inpatient (Medicare Part B nly) 013x Hspital Outpatient 014x Hspital - Labratry Services Prvided t Nn-patients 018x Hspital - Swing Beds 021x Skilled Nursing - Inpatient (Including Medicare Part A) 022x Skilled Nursing - Inpatient (Medicare Part B nly) 023x Skilled Nursing - Outpatient 028x Skilled Nursing - Swing Beds 073x Clinic - Freestanding 076x Clinic - Cmmunity Mental Health Center 077x Clinic - Federally Qualified Health Center (FQHC) 083x Ambulatry Surgery Center 085x Critical Access Hspital Revenue Cdes:

11 Cntractrs may specify Revenue Cdes t help prviders identify thse Revenue Cdes typically used t reprt this service. In mst instances Revenue Cdes are purely advisry; unless specified in the plicy services reprted under ther Revenue Cdes are equally subject t this cverage determinatin. Cmplete absence f all Revenue Cdes indicates that cverage is nt influenced by Revenue Cde and the plicy shuld be assumed t apply equally t all Revenue Cdes. Nte: The cntractr has identified the Bill Type and Revenue Cdes applicable fr use with the CPT/HCPCS cdes included in this LCD. Prviders are reminded that nt all CPT/HCPCS cdes listed can be billed with all Bill Type and/r Revenue Cdes listed. CPT/HCPCS cdes are required t be billed with specific Bill Type and Revenue Cdes. Prviders are encuraged t refer t the CMS Internet-Only Manual (IOM) Pub , Claims Prcessing Manual, fr further guidance. Place f Service (POS) CPT cdes 92541, 92542, 92543, and (prfessinal cmpnent nly), 92546, 92585, and (TC/PC services), and (technical service cmpnent nly; nt payable in POS 21, 22, 23) are payable when the service is perfrmed in POS: Office (11). Inpatient hspital (21) (prfessinal cmpnent nly). Outpatient hspital (22) (prfessinal cmpnent nly). Emergency rm (23) (prfessinal cmpnent nly). Skilled nursing facility (31). Nursing facility (32) (nly fr patients whse Part A benefits have been exhausted). Cmprehensive inpatient rehabilitatin facility (61). Cmprehensive utpatient rehabilitatin facility (62). State r lcal public health clinic (71). Cmmunity hearing and speech centers (99). Grup hme (14). Independent clinic (49). Independent Diagnstic Testing Facility (IDTF) (99). CPT cdes 92552, 92553, 92555, 92556, 92557, 92561, 92562, 92563, 92564, 92565, 92567, 92568, 92571, 92572, 92575, 92576, 92577, 92579, 92582, 92583, and are technical services-nly cdes and are payable in POS:

12 Office (11). Nursing facility (32). State r lcal health clinic (71). Cmmunity hearing and speech centers (99). Independent clinic (49). Nte: These services may nt be prvided in the hme. Nte: Prviders are reminded that nt all CPT/HCPCS cdes listed can be billed with all POS cdes listed. Prviders are encuraged t refer t the CMS Internet-Only Manual (IOM), Pub , Claims Prcessing Manual, fr further guidance. 042X Physical Therapy - General Classificatin 043X Occupatinal Therapy - General Classificatin 044X Speech Therapy - Language Pathlgy - General Classificatin 047X Audilgy - General Classificatin 096X Prfessinal Fees - General Classificatin 0971 Prfessinal Fees - Labratry 0972 Prfessinal Fees - Radilgy - Diagnstic 0973 Prfessinal Fees - Radilgy - Therapeutic 0974 Prfessinal Fees - Radilgy Nuclear 0975 Prfessinal Fees - Operating Rm 0976 Prfessinal Fees - Respiratry Therapy 0977 Prfessinal Fees - Physical Therapy 0978 Prfessinal Fees - Occupatinal Therapy 0979 Prfessinal Fees - Speech Pathlgy 0981 Prfessinal Fees - Emergency Rm Services 0982 Prfessinal Fees - Outpatient Services 0983 Prfessinal Fees - Clinic 0984 Prfessinal Fees - Medical Scial Services 0985 Prfessinal Fees - EKG 0986 Prfessinal Fees - EEG 0987 Prfessinal Fees - Hspital Visit 0988 Prfessinal Fees - Cnsultatin 0989 Prfessinal Fees - Private Duty Nurse CPT/HCPCS Cdes Grup 1 Paragraph: Nte: Prviders are reminded t refer t the lng descriptrs f the CPT cdes in their CPT bk.

13 Grup 1 Cdes: Basic vestibular evaluatin Spntaneus nystagmus test Psitinal nystagmus test Calric vestibular test Optkinetic nystagmus test Oscillating tracking test Sinusidal rtatinal test Supplemental electrical test Tympanmetry & reflex thresh Pure tne audimetry air Audimetry air & bne Speech threshld audimetry Speech audimetry cmplete Cmprehensive hearing test Evked auditry test qual Bekesy audimetry diagnsis Ludness balance test Tne decay hearing test Sisi hearing test Stenger test pure tne Tympanmetry Acustic refl threshld tst Acustic immitance testing Filtered speech hearing test Staggered spndaic wrd test Sensrineural acuity test Synthetic sentence test Stenger test speech Visual audimetry (vra) Cnditining play audimetry Select picture audimetry Electrcchlegraphy Auditr evke ptent cmpre Auditr evke ptent limit Evked auditry test limited Evked auditry tst cmplete Ear prtectr evaluatin Oral speech device eval Cchlear implt f/up exam <7

14 92602 Reprgram cchlear implt 7/> Cchlear implt f/up exam 7/> Reprgram cchlear implt 7/> Auditry functin 60 min Auditry functin + 15 min ICD-9 Cdes that Supprt Medical Necessity Grup 1 Paragraph: Nte: Prviders shuld cntinue t submit ICD-9-CM diagnsis cdes withut decimals n their claim frms and electrnic claims. The CPT/HCPCS cdes included in this LCD will be subjected t prcedure t diagnsis editing. The fllwing lists include nly thse diagnses fr which the identified CPT/HCPCS prcedures are cvered. If a cvered diagnsis is nt n the claim, the edit will autmatically deny the service as nt medically necessary. Nte: Limited cverage is nt being established fr CPT cdes 92601, 92602, and at this time. Medicare is establishing the fllwing limited cverage fr CPT/HCPCS cdes 92540, 92541, 92542, 92543, 92544, 92545, and 92547: Cvered fr: Grup 1 Cdes: MÉNIÈRE'S DISEASE, UNSPECIFIED - INACTIVE MÉNIÈRE'S DISEASE PERIPHERAL VERTIGO UNSPECIFIED - VESTIBULAR NEURONITIS OTHER PERIPHERAL VERTIGO VERTIGO OF CENTRAL ORIGIN LABYRINTHITIS UNSPECIFIED - VIRAL LABYRINTHITIS LABYRINTHINE FISTULA UNSPECIFIED - SEMICIRCULAR CANAL FISTULA LABYRINTHINE FISTULA OF COMBINED SITES LABYRINTHINE DYSFUNCTION UNSPECIFIED - LOSS OF LABYRINTHINE REACTIVITY BILATERAL OTHER FORMS AND COMBINATIONS OF LABYRINTHINE DYSFUNCTION OTHER DISORDERS OF LABYRINTH - UNSPECIFIED VERTIGINOUS SYNDROMES AND LABYRINTHINE DISORDERS SENSORINEURAL HEARING LOSS UNSPECIFIED - SENSORINEURAL HEARING LOSS, BILATERAL

15 Grup 2 Paragraph: Medicare is establishing the fllwing limited cverage fr CPT/HCPCS cdes 92550, 92552, 92553, 92555, 92556, 92557, 92567, and 92570: Cvered fr: Grup 2 Cdes: BENIGN NEOPLASM OF CRANIAL NERVES CONVERSION DISORDER ACUTE NONSUPPURATIVE OTITIS MEDIA UNSPECIFIED - ACUTE ALLERGIC SANGUINOUS OTITIS MEDIA CHRONIC SEROUS OTITIS MEDIA SIMPLE OR UNSPECIFIED OTHER CHRONIC SEROUS OTITIS MEDIA CHRONIC MUCOID OTITIS MEDIA SIMPLE OR UNSPECIFIED OTHER CHRONIC MUCOID OTITIS MEDIA OTHER AND UNSPECIFIED CHRONIC NONSUPPURATIVE OTITIS MEDIA - NONSUPPURATIVE OTITIS MEDIA NOT SPECIFIED AS ACUTE OR CHRONIC EUSTACHIAN SALPINGITIS UNSPECIFIED - CHRONIC EUSTACHIAN SALPINGITIS PATULOUS EUSTACHIAN TUBE DYSFUNCTION OF EUSTACHIAN TUBE OTHER DISORDERS OF EUSTACHIAN TUBE UNSPECIFIED EUSTACHIAN TUBE DISORDER OBSTRUCTION OF EUSTACHIAN TUBE UNSPECIFIED - EXTRINSIC CARTILAGENOUS OBSTRUCTION OF EUSTACHIAN TUBE ACUTE SUPPURATIVE OTITIS MEDIA WITHOUT SPONTANEOUS RUPTURE OF EARDRUM - ACUTE SUPPURATIVE OTITIS MEDIA IN DISEASES CLASSIFIED ELSEWHERE CHRONIC TUBOTYMPANIC SUPPURATIVE OTITIS MEDIA - UNSPECIFIED SUPPURATIVE OTITIS MEDIA UNSPECIFIED OTITIS MEDIA PERFORATION OF TYMPANIC MEMBRANE UNSPECIFIED - TOTAL PERFORATION OF TYMPANIC MEMBRANE TYMPANOSCLEROSIS UNSPECIFIED AS TO INVOLVEMENT TYMPANOSCLEROSIS INVOLVING TYMPANIC MEMBRANE EAR OSSICLES AND MIDDLE EAR TYMPANOSCLEROSIS INVOLVING OTHER COMBINATION OF STRUCTURES ADHESIVE MIDDLE EAR DISEASE UNSPECIFIED AS TO INVOLVEMENT - ADHESIONS OF DRUM HEAD TO PROMONTORIUM OTHER MIDDLE EAR ADHESIONS AND COMBINATIONS

16 IMPAIRED MOBILITY OF OTHER EAR OSSICLES - DISCONTINUITY OR DISLOCATION OF EAR OSSICLES CHOLESTEATOMA UNSPECIFIED - CHOLESTEATOMA OF MIDDLE EAR AND MASTOID DIFFUSE CHOLESTEATOSIS OF MIDDLE EAR AND MASTOID MÉNIÈRE'S DISEASE, UNSPECIFIED - INACTIVE MÉNIÈRE'S DISEASE PERIPHERAL VERTIGO UNSPECIFIED - VESTIBULAR NEURONITIS OTHER PERIPHERAL VERTIGO VERTIGO OF CENTRAL ORIGIN LABYRINTHITIS UNSPECIFIED - VIRAL LABYRINTHITIS LABYRINTHINE FISTULA UNSPECIFIED - SEMICIRCULAR CANAL FISTULA LABYRINTHINE FISTULA OF COMBINED SITES LABYRINTHINE DYSFUNCTION UNSPECIFIED - LOSS OF LABYRINTHINE REACTIVITY BILATERAL OTHER FORMS AND COMBINATIONS OF LABYRINTHINE DYSFUNCTION OTHER DISORDERS OF LABYRINTH - UNSPECIFIED VERTIGINOUS SYNDROMES AND LABYRINTHINE DISORDERS OTOSCLEROSIS INVOLVING OVAL WINDOW OBLITERATIVE NOISE-INDUCED HEARING LOSS 388.2* SUDDEN HEARING LOSS UNSPECIFIED TINNITUS UNSPECIFIED - OBJECTIVE TINNITUS ABNORMAL AUDITORY PERCEPTION UNSPECIFIED ACQUIRED AUDITORY PROCESSING DISORDER * SENSORINEURAL HEARING LOSS UNSPECIFIED - SENSORINEURAL HEARING LOSS, BILATERAL * MIXED HEARING LOSS, UNSPECIFIED - MIXED HEARING LOSS, BILATERAL V58.11 ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY V58.62 LONG-TERM (CURRENT) USE OF ANTIBIOTICS Grup 2 Medical Necessity ICD-9 Cdes Asterisk Explanatin: *Tests fr these ICD-9-CM cdes are cvered nly fr an initial evaluatin f a hearing prblem and fr subsequent evaluatin when the medical necessity is clearly dcumented in the patient s medical recrd. Grup 3 Paragraph: Medicare is establishing the fllwing limited cverage fr CPT/HCPCS cde 92561: Cvered fr:

17 Grup 3 Cdes: BENIGN NEOPLASM OF CRANIAL NERVES 388.2* SUDDEN HEARING LOSS UNSPECIFIED SENSORINEURAL HEARING LOSS UNSPECIFIED - SENSORINEURAL * HEARING LOSS, BILATERAL MIXED HEARING LOSS, UNSPECIFIED - MIXED HEARING LOSS, * BILATERAL Grup 3 Medical Necessity ICD-9 Cdes Asterisk Explanatin: *Tests fr these ICD-9-CM cdes are cvered nly fr an initial evaluatin f a hearing prblem and fr subsequent evaluatin when the medical necessity is clearly dcumented in the patient s medical recrd. Grup 4 Paragraph: Medicare is establishing the fllwing limited cverage fr CPT/HCPCS cdes and 92564: Cvered fr: Grup 4 Cdes: MÉNIÈRE'S DISEASE, UNSPECIFIED - ACTIVE MÉNIÈRE'S DISEASE, VESTIBULAR 388.2* SUDDEN HEARING LOSS UNSPECIFIED SENSORINEURAL HEARING LOSS UNSPECIFIED - SENSORINEURAL * HEARING LOSS, BILATERAL MIXED HEARING LOSS, UNSPECIFIED - MIXED HEARING LOSS, * BILATERAL Grup 4 Medical Necessity ICD-9 Cdes Asterisk Explanatin: *Tests fr these ICD-9-CM cdes are cvered nly fr an initial evaluatin f a hearing prblem and fr subsequent evaluatin when the medical necessity is clearly dcumented in the patient s medical recrd. Grup 5 Paragraph: Medicare is establishing the fllwing limited cverage fr CPT/HCPCS cde 92563: Cvered fr: Grup 5 Cdes: BENIGN NEOPLASM OF CRANIAL NERVES ACUTE NONSUPPURATIVE OTITIS MEDIA UNSPECIFIED - ACUTE ALLERGIC SANGUINOUS OTITIS MEDIA CHRONIC SEROUS OTITIS MEDIA SIMPLE OR UNSPECIFIED OTHER CHRONIC SEROUS OTITIS MEDIA CHRONIC MUCOID OTITIS MEDIA SIMPLE OR UNSPECIFIED

18 OTHER CHRONIC MUCOID OTITIS MEDIA OTHER AND UNSPECIFIED CHRONIC NONSUPPURATIVE OTITIS MEDIA NONSUPPURATIVE OTITIS MEDIA NOT SPECIFIED AS ACUTE OR CHRONIC EUSTACHIAN SALPINGITIS UNSPECIFIED - CHRONIC EUSTACHIAN SALPINGITIS OBSTRUCTION OF EUSTACHIAN TUBE UNSPECIFIED - EXTRINSIC CARTILAGENOUS OBSTRUCTION OF EUSTACHIAN TUBE PATULOUS EUSTACHIAN TUBE DYSFUNCTION OF EUSTACHIAN TUBE OTHER DISORDERS OF EUSTACHIAN TUBE UNSPECIFIED EUSTACHIAN TUBE DISORDER ACUTE SUPPURATIVE OTITIS MEDIA WITHOUT SPONTANEOUS RUPTURE OF EARDRUM - ACUTE SUPPURATIVE OTITIS MEDIA IN DISEASES CLASSIFIED ELSEWHERE CHRONIC TUBOTYMPANIC SUPPURATIVE OTITIS MEDIA - UNSPECIFIED SUPPURATIVE OTITIS MEDIA UNSPECIFIED OTITIS MEDIA PERFORATION OF TYMPANIC MEMBRANE UNSPECIFIED - TOTAL PERFORATION OF TYMPANIC MEMBRANE TYMPANOSCLEROSIS UNSPECIFIED AS TO INVOLVEMENT TYMPANOSCLEROSIS INVOLVING TYMPANIC MEMBRANE EAR OSSICLES AND MIDDLE EAR TYMPANOSCLEROSIS INVOLVING OTHER COMBINATION OF STRUCTURES ADHESIVE MIDDLE EAR DISEASE UNSPECIFIED AS TO INVOLVEMENT - ADHESIONS OF DRUM HEAD TO PROMONTORIUM OTHER MIDDLE EAR ADHESIONS AND COMBINATIONS IMPAIRED MOBILITY OF OTHER EAR OSSICLES - DISCONTINUITY OR DISLOCATION OF EAR OSSICLES CHOLESTEATOMA UNSPECIFIED - CHOLESTEATOMA OF MIDDLE EAR AND MASTOID DIFFUSE CHOLESTEATOSIS OF MIDDLE EAR AND MASTOID MÉNIÈRE'S DISEASE, UNSPECIFIED - INACTIVE MÉNIÈRE'S DISEASE PERIPHERAL VERTIGO UNSPECIFIED - VESTIBULAR NEURONITIS OTHER PERIPHERAL VERTIGO VERTIGO OF CENTRAL ORIGIN LABYRINTHITIS UNSPECIFIED - VIRAL LABYRINTHITIS LABYRINTHINE FISTULA UNSPECIFIED - SEMICIRCULAR CANAL FISTULA LABYRINTHINE FISTULA OF COMBINED SITES

19 LABYRINTHINE DYSFUNCTION UNSPECIFIED - LOSS OF LABYRINTHINE REACTIVITY BILATERAL OTHER FORMS AND COMBINATIONS OF LABYRINTHINE DYSFUNCTION OTHER DISORDERS OF LABYRINTH - UNSPECIFIED VERTIGINOUS SYNDROMES AND LABYRINTHINE DISORDERS 388.2* SUDDEN HEARING LOSS UNSPECIFIED TINNITUS UNSPECIFIED - OBJECTIVE TINNITUS SENSORINEURAL HEARING LOSS UNSPECIFIED - SENSORINEURAL * HEARING LOSS, BILATERAL MIXED HEARING LOSS, UNSPECIFIED - MIXED HEARING LOSS, * BILATERAL Grup 5 Medical Necessity ICD-9 Cdes Asterisk Explanatin: *Tests fr these ICD-9-CM cdes are cvered nly fr an initial evaluatin f a hearing prblem and fr subsequent evaluatin when the medical necessity is clearly dcumented in the patient s medical recrd. Grup 6 Paragraph: Medicare is establishing the fllwing limited cverage fr CPT/HCPCS cdes and 92577: Cvered fr: Grup 6 Cdes: CONVERSION DISORDER V65.2 PERSON FEIGNING ILLNESS Grup 7 Paragraph: Medicare is establishing the fllwing limited cverage fr CPT/HCPCS cdes 92571, 92572, 92576, and 92621: Cvered fr: Grup 7 Cdes: MÉNIÈRE'S DISEASE, UNSPECIFIED - INACTIVE MÉNIÈRE'S DISEASE PERIPHERAL VERTIGO UNSPECIFIED - VESTIBULAR NEURONITIS OTHER PERIPHERAL VERTIGO VERTIGO OF CENTRAL ORIGIN LABYRINTHITIS UNSPECIFIED - VIRAL LABYRINTHITIS LABYRINTHINE FISTULA UNSPECIFIED - SEMICIRCULAR CANAL FISTULA LABYRINTHINE FISTULA OF COMBINED SITES

20 LABYRINTHINE DYSFUNCTION UNSPECIFIED - LOSS OF LABYRINTHINE REACTIVITY BILATERAL OTHER FORMS AND COMBINATIONS OF LABYRINTHINE DYSFUNCTION OTHER DISORDERS OF LABYRINTH - UNSPECIFIED VERTIGINOUS SYNDROMES AND LABYRINTHINE DISORDERS SENSORINEURAL HEARING LOSS UNSPECIFIED - SENSORINEURAL * HEARING LOSS, BILATERAL MIXED HEARING LOSS, UNSPECIFIED - MIXED HEARING LOSS, * BILATERAL Grup 7 Medical Necessity ICD-9 Cdes Asterisk Explanatin: *Tests fr these ICD-9-CM cdes are cvered nly fr an initial evaluatin f a hearing prblem and fr subsequent evaluatin when the medical necessity is clearly dcumented in the patient s medical recrd. Grup 8 Paragraph: Medicare is establishing the fllwing limited cverage fr CPT/HCPCS cde 92575: Cvered fr: Grup 8 Cdes: MÉNIÈRE'S DISEASE, UNSPECIFIED - INACTIVE MÉNIÈRE'S DISEASE PERIPHERAL VERTIGO UNSPECIFIED - VESTIBULAR NEURONITIS OTHER PERIPHERAL VERTIGO VERTIGO OF CENTRAL ORIGIN LABYRINTHITIS UNSPECIFIED - VIRAL LABYRINTHITIS 388.2* SUDDEN HEARING LOSS UNSPECIFIED TINNITUS UNSPECIFIED - OBJECTIVE TINNITUS SENSORINEURAL HEARING LOSS UNSPECIFIED - SENSORINEURAL * HEARING LOSS, BILATERAL MIXED HEARING LOSS, UNSPECIFIED - MIXED HEARING LOSS, * BILATERAL Grup 8 Medical Necessity ICD-9 Cdes Asterisk Explanatin: *Tests fr these ICD-9-CM cdes are cvered nly fr an initial evaluatin f a hearing prblem and fr subsequent evaluatin when the medical necessity is clearly dcumented in the patient s medical recrd. Grup 9 Paragraph: Medicare is establishing the fllwing limited cverage fr CPT/HCPCS cdes and 92583: Cvered fr:

21 Grup 9 Cdes: 317 MILD INTELLECTUAL DISABILITIES MODERATE INTELLECTUAL DISABILITIES - PROFOUND INTELLECTUAL DISABILITIES 319 UNSPECIFIED INTELLECTUAL DISABILITIES Grup 10 Paragraph: Medicare is establishing the fllwing limited cverage fr CPT/HCPCS cde 92584: Cvered fr: Grup 10 Cdes: BENIGN NEOPLASM OF CRANIAL NERVES MÉNIÈRE'S DISEASE, UNSPECIFIED - INACTIVE MÉNIÈRE'S DISEASE 388.2* SUDDEN HEARING LOSS UNSPECIFIED TINNITUS UNSPECIFIED SENSORINEURAL HEARING LOSS UNSPECIFIED - SENSORINEURAL * HEARING LOSS, BILATERAL MIXED HEARING LOSS, UNSPECIFIED - MIXED HEARING LOSS, * BILATERAL Grup 10 Medical Necessity ICD-9 Cdes Asterisk Explanatin: *Tests fr these ICD-9- CM cdes are cvered nly fr an initial evaluatin f a hearing prblem and fr subsequent evaluatin when the medical necessity is clearly dcumented in the patient s medical recrd. Grup 11 Paragraph: Medicare is establishing the fllwing limited cverage fr CPT/HCPCS cdes and 92586: Cvered fr: Grup 11 Cdes: BENIGN NEOPLASM OF CRANIAL NERVES OTHER DEGENERATIVE DISEASES OF THE BASAL GANGLIA - GENETIC TORSION DYSTONIA ATHETOID CEREBRAL PALSY - ACUTE DYSTONIA DUE TO DRUGS OTHER ACQUIRED TORSION DYSTONIA BLEPHAROSPASM - SUBACUTE DYSKINESIA DUE TO DRUGS OTHER FRAGMENTS OF TORSION DYSTONIA UNSPECIFIED EXTRAPYRAMIDAL DISEASE AND ABNORMAL MOVEMENT DISORDER - BENIGN SHUDDERING ATTACKS

22 OTHER EXTRAPYRAMIDAL DISEASES AND ABNORMAL MOVEMENT DISORDERS 340 MULTIPLE SCLEROSIS NEUROMYELITIS OPTICA - SCHILDER'S DISEASE ACUTE (TRANSVERSE) MYELITIS NOS - IDIOPATHIC TRANSVERSE MYELITIS OTHER DEMYELINATING DISEASES OF CENTRAL NERVOUS SYSTEM DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED OPTIC NEURITIS UNSPECIFIED - TOXIC OPTIC NEUROPATHY OTHER OPTIC NEURITIS MÉNIÈRE'S DISEASE, UNSPECIFIED - INACTIVE MÉNIÈRE'S DISEASE VERTIGO OF CENTRAL ORIGIN NOISE-INDUCED HEARING LOSS 388.2* SUDDEN HEARING LOSS UNSPECIFIED TINNITUS UNSPECIFIED - OBJECTIVE TINNITUS DISORDERS OF ACOUSTIC NERVE * SENSORINEURAL HEARING LOSS UNSPECIFIED - SENSORINEURAL HEARING LOSS, BILATERAL * MIXED HEARING LOSS, UNSPECIFIED - MIXED HEARING LOSS, BILATERAL DIZZINESS AND GIDDINESS ABNORMAL INVOLUNTARY MOVEMENTS Grup 11 Medical Necessity ICD-9 Cdes Asterisk Explanatin: *Tests fr these ICD-9- CM cdes are cvered nly fr an initial evaluatin f a hearing prblem and fr subsequent evaluatin when the medical necessity is clearly dcumented in the patient s medical recrd. Grup 12 Paragraph: Medicare is establishing the fllwing limited cverage fr CPT/HCPCS cdes 92579, and 92588: Cvered fr: Grup 12 Cdes: NOISE-INDUCED HEARING LOSS 388.2* SUDDEN HEARING LOSS UNSPECIFIED TINNITUS UNSPECIFIED - OBJECTIVE TINNITUS * SENSORINEURAL HEARING LOSS UNSPECIFIED - SENSORINEURAL HEARING LOSS, BILATERAL

23 MIXED HEARING LOSS, UNSPECIFIED - MIXED HEARING LOSS, * BILATERAL Grup 12 Medical Necessity ICD-9 Cdes Asterisk Explanatin: *Tests fr these ICD-9- CM cdes are cvered nly fr an initial evaluatin f a hearing prblem and fr subsequent evaluatin when the medical necessity is clearly dcumented in the patient s medical recrd. Grup 13 Paragraph: Medicare is establishing the fllwing limited cverage fr CPT/HCPCS cdes and 92597: Cvered fr: Grup 13 Cdes: MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER MALIGNANT NEOPLASM OF COMMISSURE OF LIP MALIGNANT NEOPLASM OF OTHER SITES OF LIP - MALIGNANT NEOPLASM OF LIP UNSPECIFIED VERMILION BORDER MALIGNANT NEOPLASM OF BASE OF TONGUE - MALIGNANT NEOPLASM OF LINGUAL TONSIL MALIGNANT NEOPLASM OF OTHER SITES OF TONGUE - MALIGNANT NEOPLASM OF TONGUE UNSPECIFIED MALIGNANT NEOPLASM OF PAROTID GLAND - MALIGNANT NEOPLASM OF SUBLINGUAL GLAND MALIGNANT NEOPLASM OF OTHER MAJOR SALIVARY GLANDS MALIGNANT NEOPLASM OF SALIVARY GLAND UNSPECIFIED MALIGNANT NEOPLASM OF UPPER GUM - MALIGNANT NEOPLASM OF LOWER GUM MALIGNANT NEOPLASM OF OTHER SITES OF GUM - MALIGNANT NEOPLASM OF GUM UNSPECIFIED MALIGNANT NEOPLASM OF ANTERIOR PORTION OF FLOOR OF MOUTH MALIGNANT NEOPLASM OF LATERAL PORTION OF FLOOR OF MOUTH MALIGNANT NEOPLASM OF OTHER SITES OF FLOOR OF MOUTH MALIGNANT NEOPLASM OF FLOOR OF MOUTH PART UNSPECIFIED MALIGNANT NEOPLASM OF CHEEK MUCOSA - MALIGNANT NEOPLASM OF RETROMOLAR AREA MALIGNANT NEOPLASM OF OTHER SPECIFIED PARTS OF MOUTH MALIGNANT NEOPLASM OF MOUTH UNSPECIFIED MALIGNANT NEOPLASM OF TONSIL - MALIGNANT NEOPLASM OF OROPHARYNX UNSPECIFIED SITE MALIGNANT NEOPLASM OF SUPERIOR WALL OF NASOPHARYNX MALIGNANT NEOPLASM OF ANTERIOR WALL OF NASOPHARYNX MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF NASOPHARYNX MALIGNANT NEOPLASM OF NASOPHARYNX UNSPECIFIED SITE

24 MALIGNANT NEOPLASM OF POSTCRICOID REGION OF HYPOPHARYNX - MALIGNANT NEOPLASM OF POSTERIOR HYPOPHARYNGEAL WALL MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF HYPOPHARYNX - MALIGNANT NEOPLASM OF HYPOPHARYNX UNSPECIFIED SITE MALIGNANT NEOPLASM OF PHARYNX UNSPECIFIED - MALIGNANT NEOPLASM OF WALDEYER'S RING MALIGNANT NEOPLASM OF OTHER SITES WITHIN THE LIP AND ORAL CAVITY - MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE LIP AND ORAL CAVITY MALIGNANT NEOPLASM OF GLOTTIS - MALIGNANT NEOPLASM OF LARYNGEAL CARTILAGES MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARYNX - MALIGNANT NEOPLASM OF LARYNX UNSPECIFIED SPEECH AND LANGUAGE DEFICIT UNSPECIFIED - DYSPHASIA OTHER SPEECH AND LANGUAGE DEFICITS UNSPECIFIED PARALYSIS OF VOCAL CORDS - COMPLETE BILATERAL PARALYSIS OF VOCAL CORDS APHASIA DYSARTHRIA OTHER SPEECH DISTURBANCE OTHER SYMPTOMS INVOLVING HEAD AND NECK CLOSED FRACTURE OF LARYNX AND TRACHEA - OPEN FRACTURE OF LARYNX AND TRACHEA CRUSHING INJURY OF NECK V10.21 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF LARYNX V10.29 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER RESPIRATORY AND INTRATHORACIC ORGANS V52.8 FITTING AND ADJUSTMENT OF OTHER SPECIFIED PROSTHETIC DEVICE ICD-9 Cdes that DO NOT Supprt Medical Necessity Paragraph: N/A General Infrmatin Assciated Infrmatin Dcumentatin Requirements Dcumentatin supprting the medical necessity shuld be legible, maintained in the patient s medical recrd and made available t Medicare upn request.

25 Each claim must be submitted with ICD-9-CM cdes that reflect the cnditin f the patient and indicate the reasn(s) fr which the service was perfrmed. Claims submitted withut ICD-9-CM cdes will be returned. Audilgists must always include the Natinal Prvider Identifier (NPI) number f the physician/npp rdering the testing n their claims. The ttal number f timed minutes must be dcumented in the medical recrd. The ther diagnstic tests benefit requires an rder frm a physician r, where allwed by state and lcal law, by an NPP. The reasn fr the test shuld be dcumented either n the rder, the audilgical evaluatin reprt, r in the patient s medical recrd. Examples f apprpriate reasns include but are nt limited t: 1. Evaluatin f suspected change in hearing, tinnitus r balance. 2. Evaluatin f the cause f disrders f hearing, tinnitus r balance. 3. Determinatin f the effect f medicatin, surgery r ther treatment. 4. Re-evaluatin (fllw-up changes in hearing, tinnitus r balance) that may be caused by but are nt limited t tsclersis, atelectatic tympanic membrane, tympansclersis, chlesteatma, reslving middle-ear infectin, Meniere s disease, sudden idipathic sensrineural hearing lss, autimmune inner-ear disease, acustic neurma, demyelinating diseases, ttxicity secndary t medicatins, genetic, vascular and viral cnditins. 5. Screening tests are nt payable, but failure f a screening test may be an apprpriate reasn fr diagnstic audilgical tests. The medical recrd shall identify the name and prfessinal identity f the persn wh rdered the service and the persn wh actually perfrmed the service. When the medical recrd is subject t medical review, it is necessary fr the Cntractr t determine that the service qualifies as an audilgical diagnstic test that requires the skills f an audilgist. A technician must meet qualificatins determined by the Medicare Cntractr t whm the claim is billed. At a minimum, the qualificatins must include the requirements f any applicable state r lcal laws and successful cmpletin f a curriculum including bth classrm training and supervised clinical experience in administratin f the audilgical service. If a technician perfrms the technical cmpnent f a service that des nt require the skills f an audilgist, the physician supervisr shall prvide and dcument the physician s prfessinal cmpnent f the service including, clinical decisin-making and ther active participatin in the delivery f the service. This participatin may nt als be billed as evaluatin and management r as part f ther billed services. Utilizatin Guidelines

26 Prcedure cde is nt a cvered service fr PT perfrmed by OT r SLP may be billed n mre than nce per prvider, per discipline, per date f service, per patient. See CMS Change Request 5253 fr additinal details.) When mnitring fr antibitic-induced ttxicity, it is anticipated that the audilgic testing (CPT cdes 92553, 92557, and 92568) services may be perfrmed as frequently as nce a mnth during the perid in which the beneficiary is receiving the antibitic. The fllwing utilizatin guidelines are based n infrmatin frm the Cder s Desk Reference: Medicare will nt cver the fllwing prcedures mre than nce during a sessin (same date f service): Electrnystagmgraphy (ENG) electrdes are placed n the patient t measure the difference between the patient s right and left vestibular functins. Recrdings are made t detect spntaneus nystagmus An ENG recrding is made f the rapid eye mvements ccurring when the patient s head is placed in a variety f psitins, e.g., supine with head extended drsally, left, right and sitting. This is ften dne using infrared vide recrding systems. Nte: Based n the descriptin f 92542, the allwed amunt includes a minimum f fur psitins. This test shuld nt be billed tw times fr tw psitins, r any multiple increments This test is usually dne with a rtating drum f alternating light and dark vertical stripes. The drum is placed in frnt f the patient wh is instructed t stare at the drum withut fcusing n a stripe. The drum is then rtated in ne directin, reversed and rtated in the ppsite directin. ENG electrdes are used t recrd nystagmus ENG electrdes are placed n the patient wh is then asked t fllw a swinging bject (i.e., a ball) n a string. A recrding is made f the patient s eye while it tracks the mtin. The recrding is then analyzed fr smthness This test is dne by seating the patient in a rtating chair and bending his head frward thirty degrees. ENG electrdes are placed n the patient t measure nystagmus while the chair is rtated. The patient s eyes remain clsed during the prcedure. A recrding is made and studied t determine if there is an abnrmal labyrinthine respnse n ne side r the ther. Medicare will nt cver the fllwing prcedure mre than fur times during a sessin (same date f service):