Local Coverage Determination (LCD) for Audiological Testing; Audiological Services (L27558)

Transcription

1 Page 1 of 23 Search Home Medicare Medicaid CHIP About CMS Regulations & Guidance Research, Statistics, Data & Systems Outreach & Education People with Medicare & Medicaid Questions Careers Newsroom Contact CMS Acronyms Help Print Back to Search Results Local Coverage Determination (LCD) for Audiological Testing; Audiological Services (L27558) Select the Print Record, Add to Basket or Record buttons to print the record, to add it to your basket or to the record. Section Navigation Select Section Go Contractor Information Contractor Name Palmetto GBA Contractor Number Contractor Type MAC - Part A Back to Top LCD Information Document Information LCD ID Number L27558 LCD Title Audiological Testing; Audiological Services Contractor's Determination Number J1A L AMA CPT/ADA CDT Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or Primary Geographic Jurisdiction American Samoa California - Entire State Guam Hawaii Nevada Northern Mariana Islands Oversight Region Region X Original Determination Effective Date For services performed on or after 08/20/2008 Original Determination Ending Date

2 Page 2 of 23 dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. Revision Effective Date For services performed on or after 02/16/2012 Revision Ending Date CMS National Coverage Policy Language quoted from the Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR [b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review a NCD. See 1869(f)(1)(A)(i) of the Social Security Act. Title XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Title XVIII of the Social Security Act, 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which "are not reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member." Title XVIII of the Social Security Act, 1862(a)(7) excludes coverage for routine physical examinations, hearing aids, and examinations for hearing aids. CMS Manual System, Pub , Medicare Benefit Policy Manual, Chapter 1, 50 Other Diagnostic or Therapeutic Items or Services CMS Manual System, Pub , Medicare Benefit Policy Manual, Chapter 15, 80.3 Audiology Services CMS Manual System, Pub , Medicare Benefit Policy Manual, Chapter 16, 90 Routine Services and Appliances and 100 Hearing Aids and Auditory Implants CMS Manual System, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part Cochlear Implantation, 50.5 Oxygen Treatment of Inner Ear/Carbon Therapy, 50.6 Tinnitus Masking and 50.7 Cochleostomy With Neurovascular Transplant for Meniere's Disease CMS Manual System, Pub , Medicare Claims Processing Manual, Chapter 6, 10.3 Types of Services Subject to the Consolidated Billing Requirement for SNFs CMS Manual System, Pub , Medicare Claims Processing Manual, Chapter 7, 40.1 Audiologic Tests CMS Manual System, Pub , Medicare Claims Processing Manual, Chapter 12, 30.3 Audiology Services Indications and Limitations of Coverage and/or Medical Necessity This LCD describes coverage for audiometric and otologic evaluation procedures and evaluative and/or therapeutic services following cochlear implants. The audiometric tests listed below imply the use of calibrated electronic equipment. Other hearing tests (such as

3 Page 3 of 23 whispered voice, tuning fork) are considered part of the general otorhinolaryngologic and audiology services and are not reported separately. All descriptors refer to testing both ears. 1. Diagnostic otologic evaluation services are used to determine the medical basis of a hearing deficit. Diagnostic audiology evaluation services are used to determine the nature and degree of hearing loss that form the basis of the medical diagnosis. Diagnostic audiology evaluation services also determine the functional effect on the patient s activity and participation and form the basis for intervention. The assessment of a deficit involves both physical and physiological measurements for appropriate diagnosis and referral. 2. Covered audiology services following cochlear implant include fitting the transmitter and speech processor and diagnostic mapping of the electrode array and programming (92601, 92602, 92603, 92604). 3. All covered services are delivered subsequent to a physician order and by licensed audiologists within the scope of practice defined by the state in which the services are provided. Audiometry: audiometry tests measure hearing sensitivity and acuity. Adequate testing requires an audiometer (device for presenting sounds to the patient at precisely controlled intensity), a sound-treated environment, a qualified audiologist, and a cooperative patient. The standard testing battery includes: Pure Tone Audiometry (tests the ability to hear specific tones), Speech Audiometry (tests the ability to hear and understand spoken words), and Immittance Audiometry (test of middle ear function) with acoustic reflexes (test of middle ear muscle in response to sound). 1. Pure Tone Audiometry (threshold) (92552, 92553): This is a graphic plot of the patient's thresholds of audiometry sensitivity for pure tone (sine wave) stimuli. Threshold hearing levels are indicated for each frequency tested. Normal hearing levels are shown at the top of a graph; a decrease in hearing sensitivity is indicated by larger values of hearing level. Sounds are tested with presentation by air conduction (earphones) as well as bone conduction (skull vibrator). The pattern of air conduction and bone conduction thresholds is diagnostically significant. Generally, air conduction and bone conduction thresholds are similar in sensorineural losses. In conductive hearing losses, bone conduction is normal or near normal, but air conduction thresholds are elevated. In a mixed hearing loss, there is difference between bone conduction and air conduction thresholds (the conductive component), but both air conduction and bone conduction thresholds are elevated. 2. Speech Audiometry threshold (92555, 92556): A. Speech audiometry provides information about hearing handicap. The problem may be worse than indicated by pure tone average (PTA) for the speech frequencies. B. Speech audiometry is useful to determine candidacy for a hearing aid. C. Very poor results, out of proportion to PTA, suggest probable retrocochlear cause of hearing loss. D. Tests use spoken words and sentences rather than pure tones to assess

4 Page 4 of 23 sensitivity (threshold) or understanding (intelligibility). Speech Reception Threshold - the level at which the patient can correctly repeat 50% of test materials (spondaic words i.e. bisyllabic word with similar stress on the two syllables used to test speech reception.) Speech Recognition - the percentage of words or sentences presented at a comfortable level above the speech reception threshold that a patient can correctly repeat. 3. Immittance Audiometry: Immittance audiometry uses electroacoustic immittance equipment. A. Immittance audiometry quantifies the flow of sound energy through the eardrum and middle ear structures by bouncing a probe tone off the tympanic membrane and measuring the proportion of reflected sound. Immittance testing can measure either the impedance or admittance. The term "immittance" is used to refer to both types of measurements. B. Immittance audiometry assesses middle ear integrity. Immittance patterns can determine the presence of a variety of eardrum and middle ear pathologies. Maximal reflection of sound occurs when the membrane is very stiff, while a compliant membrane transmits more sound and reflects less. The physical properties of the eardrum and middle ear structures (e.g., ossicles) contribute to the immittance pattern. There are two principal applications of this device: Tympanometry and reflex threshold measurements (92550): This CPT code combines tympanometry (impedance testing) (92567) with acoustic reflex testing; threshold (92568). Tympanometry (impedance testing) (92567): A tympanogram is a graphic representation of dynamic acoustic immittance as a function of air pressure introduced into the external ear canal. Impedance is the lowest (maximal compliance) when pressure in the canal equals pressure in the middle ear. Diagnostic findings are described in terms of static acoustic immittance (compliance), dynamic acoustic immittance pattern, middle ear pressure, and ear canal volume. Ears may be classified into four basic types on the basis of the configuration of the tympanogram: Type A (normal), Type B (flat, consistent with middle ear effusion), Type C (retracted, consistent with negative middle ear pressure), and Type Ad (high compliance, usually indicative of ossicular discontinuity or eardrum scarring. Acoustic Reflex Testing; threshold (92568): Contraction of the stapedius muscle occurs with loud sounds, producing a measurable change in compliance. Acoustic Immittance Testing (92570): This procedure combines tympanometry (impedance testing) (92567), acoustic reflex threshold testing (92568), and acoustic reflex decay testing.

5 Page 5 of Diagnostic Audiometry: Consists of a battery of tests intended to determine the site of lesion in patients with otologic or neurologic disorders. The constellation of tests varies according to the available test battery and provisional diagnosis. A. Immittance Audiometry: (see above) B. PIPB (Performance Intensity Function for Phonetically Balanced Words) Functions: Word recognition testing performed at a level significantly above the previous level utilized for word recognition testing. This open set of monosyllabic words is presented at an elevated level and the score is compared back to that of the previous word recognition test. If a decline of 20% or greater is noted, the PIPB evaluation is considered abnormal. Additional diagnostic testing might be required to rule out retrocochlear pathology. Speech discrimination is plotted as a function of sound intensity. Normally, discrimination improves with intensity up to a maximal level, then plateaus. In eighth cranial nerve disorders, discrimination often declines dramatically as intensity increases above the level yielding maximum performances. C. Bekesy Audiometry; diagnostic (92561): The patient traces his own auditory threshold by means of a self-recording audiometer. Tracings are obtained for pulsed as well as continuous tones. The relationship between the two categories can be categorized into diagnostic patterns. (Industrial and military hearing screening situations use code These screenings are noncovered.) D. Loudness balance test, alternate binaural or monaural (92562): This test compares how loud sound is in one ear compared to the other. E. Tone Decay Test (92563): A constant sound is given to see if the ability to hear sound weakens with time. The test differentiates between sensory hearing loss and neural hearing loss. Abnormal adaptation to a continuous tone is seen in retrocochlear lesions. F. Short increment sensitivity index (SISI) (92564): Test of recruitment in which very small increases in loudness are provided - the normal ear will not discriminate the difference but the sensorineural-impaired ear may. G. Stenger Test - pure tone, (92565) or speech (92577): These are functional tests to determine validity of test results. A sound (tone or speech) is given into both ears at the same time to see if there are differences. The test is often performed to detect malingering of unilateral loss. H. Acoustic reflex testing, threshold (92568): This test checks on sound traveling from the middle ear to the inner ear. This test is often used in infants who are too young for other tests. I. Filtered speech test (92571): The subject is asked to repeat words that sound muffled. The test stimuli consist of one syllable words that have been low-pass filtered at 500 Hz. Two practice words and 20 test words are presented to each ear. Perception is tested in everyday situations (background noise, rapid speech rate, poor articulation, accent, dialect, etc.). This test is used to detect a central auditory processing disorder. J. Staggered spondaic word test (92572) (also called the SSW test): This test is given as part of a larger battery of diagnostic tests to determine central

6 Page 6 of 23 auditory processing disorders (CAPD). The patient is asked to repeat a group of words presented to one or both ears at the same time. The purpose of the test is to determine how well the patient understands, interprets, and remembers a spoken message. This test is commonly used with children. K. Lombard test: A functional test to determine the validity of test results. A masking sound is introduced while the patient is speaking. Malingerers raise the volume of their own speech to match the masking sound. The Stenger Test is used more commonly than the Lombard test. L. Sensorineural acuity level test (92575) Rinne and Weber Tests - the use of tuning forks to assess conductive or sensorineural hearing loss. This test may also be performed with audiometric equipment. M. Synthetic Sentence Identification (SSI) Test (92576) The patient hears 2 different sentences, 1 in the right ear and 1 in the left ear. The patient is asked to repeat only the sentence heard in the directed ear. This test is useful in the diagnosis of central auditory processing disorders. N. Visual reinforcement audiometry (VRA) (92579): A behavioral test for infants or young children. The child is given an animated toy for turning towards sounds. (Coverage is limited to infants, very young children, or beneficiaries with severe mental retardation. This test is non-covered if used as a screening.) O. Conditioning play audiometry (CPA) (92582): A behavioral test for infants or young children. The child is trained to respond to tones by playing a game. (Coverage is limited to infants, young children, or beneficiaries with severe mental retardation. This test is non-covered if used as a screening.) P. ECOG (Electrocochleography ): Electrical activity evoked from the cochlear or auditory nerve is measured from the tympanic membrane or ear canal and responses to a large number of clicks are averaged. These will be abnormal in eighth cranial nerve lesions and certain cochlear disorders. This test is commonly performed with electrodes placed in the ear canal or on the eardrum. Q. ABR (Auditory brainstem response) - Audiometry evoked potentials for evoked response audiometry and/or testing of the central nervous system: ( comprehensive, and limited): Scalp electrodes measure electrical activity in the auditory nerve and brainstem in response to sound clicks. The response is quite small in relation to other ongoing brain activity, but, by presenting a large number of clicks and averaging the responses by computer, unrelated events can be canceled out. This is useful for documenting hearing in uncooperative or unresponsive patients. The disadvantage is that it tests mainly the 1,000-4,000 Hertz frequency range of hearing and is a poor indicator of the overall auditory function. An abnormal ABR is seen in eighth nerve or brainstem lesions. R. Distortion product evoked otoacoustic emissions; limited (92587) or distortion product evoked otoacoustic emissions; comprehensive (92588): The diagnostic test measures cochlear activity in response to clicks or pairs of tones. Transient emissions are responses to clicks and give an overall picture of cochlear functions across a wide range of frequencies. Distortion product emissions are responses to pairs of tones and can be used to determine physiologic thresholds at specific frequencies. Often used as a screening test in infants (92587) or as a diagnostic test for a detailed assessment of cochlear

7 Page 7 of 23 function and site of lesion determination (92588). S. Evaluation of auditory rehabilitation status; first hour (92626) or each additional 15 minutes (92627): This service is used to evaluate a patient s need and suitability for aural rehabilitation. The assessment addresses, in children and adults, dimensions of impairment, activity limitation, participation restriction, and applicable environmental and contextual factors. These timed codes are for evaluation of auditory rehabilitation to instruct the use of residual hearing provided by an implant or hearing aid related to hearing loss. Evaluation of auditory rehabilitation shall be appropriately provided and billed by an audiologist or speech-language pathologist. Also, these services may be provided incident to a physician's or qualified NPP's (nonphysician practitioner s) service by a speech-language pathologist, or personally by a physician or qualified NPP within their scope of practice. Evaluation of auditory rehabilitation is a covered diagnostic test when performed and billed by an audiologist and is an SLP evaluation service covered under the SLP benefit when performed by a speech-language pathologist." Audiology tests are covered as other diagnostic tests under section 1861(s)(3) or 1861(s)(2)(C) of the Act in the physician s office or hospital outpatient settings, respectively, when a physician (or an NPP, as applicable) orders such testing for the purpose of obtaining information necessary for the physician s diagnostic medical evaluation or to determine the appropriate medical or surgical treatment of a hearing deficit or related medical problem. 1. Diagnostic audiometric tests are covered to determine the appropriate medical/surgical treatment for auditory deficits or other related medical problems. 2. For conductive hearing loss, hearing should be retested after medical or surgical treatment. For sensorineural hearing loss, the audiologist or physician will recommend when repeat testing should be done. Since hearing may change or fluctuate, it is important to detect this as early as possible to prevent further loss and to obtain medical treatment, if needed. 3. Audiologic Function Tests (CPT codes 92553, 92557, 92568) may be performed for patients on continuing (current) long-term (more than 7 days) use of medications known to be ototoxic. Hearing tests for the purpose of prescribing, selecting, or fitting a hearing aid are specifically excluded from coverage by Medicare. Hearing tests are performed on a graduated basis proceeding until a cause or source of the hearing loss is evident. The test types are either basic or site-of-lesion. Hearing tests can be covered for the following diagnoses or conditions: 1. Trauma 2. Neoplasms (tumors) A. Malignant B. Benign

8 Page 8 of Diseases/conditions of external ear 4. Diseases/conditions of middle ear A. Otitis media 5. Diseases/conditions of the tympanic membrane 6. Other diseases/conditions of the ear 7. Other conditions that can affect hearing 8. Symptoms associated with ototoxic medication treatment (including baseline and semi-annual monitoring for patients on long term use of prescription ototoxic medications.) 9. Symptoms/Diseases/Conditions associated with hearing or balance (other than muscular or orthopedic changes). A. Vertigo-initial evaluation/recent onset B. Tinnitus-initial evaluation/recent onset C. Asymmetrical hearing loss-initial evaluations/recent onset D. "Sudden" hearing loss-initial evaluation/recent onset E. Abnormal findings in neurological evaluations F. Meniere's disease G. Subjective change in hearing ability Audiological diagnostic procedures conducted before the ear canals are free of cerumen are considered not reasonable and necessary. All hearing exams refer to testing which uses calibrated electronic equipment. Frequencies allowed for services following cochlear implant ( ) are limited by patient age. Adults: The transmitter and speech processor are fitted 4-6 weeks after surgery; weekly adjustments of the program and communication therapy for 1 month following fitting; more than 4 follow up visits, or follow up visits more than 4 weeks after fitting of the transmitter and speech processor will be reviewed for medical necessity on an individual basis. Children (under age 17): fitting continues over a 3-month period. Young children are seen 2-3 times a week for the first month and 1-2 times a week for the next 2 months; follow up after the initial 3-month period is every 3 months for the first year and every 6 months for the second and third years, then annually through age 16. Follow up at greater frequency or for longer duration will be reviewed for medical necessity on an individual basis.

9 Page 9 of 23 Back to Top Coding Information Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. 012x 013x 018x Hospital Inpatient (Medicare Part B only) Hospital Outpatient Hospital - Swing Beds 021x Skilled Nursing - Inpatient (Including Medicare Part A) 022x 023x 085x Skilled Nursing - Inpatient (Medicare Part B only) Skilled Nursing - Outpatient Critical Access Hospital Revenue Codes: Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes Audiology - General Classification CPT/HCPCS Codes Audiologic Function Tests with medical diagnostic evaluation NOTE: CPT codes and are non-covered if used as a screening Tympanometry & reflex thresh Pure tone audiometry air Audiometry air & bone Speech threshold audiometry Speech audiometry complete

10 Page 10 of Comprehensive hearing test Bekesy audiometry diagnosis Loudness balance test Tone decay hearing test Sisi hearing test Stenger test pure tone Tympanometry Acoustic refl threshold tst Acoustic immitance testing Filtered speech hearing test Staggered spondaic word test Sensorineural acuity test Synthetic sentence test Stenger test speech Visual audiometry (vra) Conditioning play audiometry Select picture audiometry Electrocochleography Auditor evoke potent compre Auditor evoke potent limit Evoked auditory test limited Evoked auditory tst complete Eval aud rehab status Eval aud status rehab add-on Non-Covered Procedures Speech/hearing therapy Speech/hearing therapy

11 Page 11 of Pure tone hearing test air Group audiometric testing Bekesy audiometry screen Visual audiometry (vra) Conditioning play audiometry Hearing aid exam one ear - Ear protector evaluation Services following Cochlear Implant Cochlear implt f/up exam < Reprogram cochlear implt < Cochlear implt f/up exam 7 > Reprogram cochlear implt 7 > New Codes (replacement of Audiological Function Tests with medical diagnostic eva Auditory function 60 min Auditory function + 15 min Tinnitus assessment ICD-9 Codes that Support Medical Necessity 1. Spanned codes include all 4 th and 5 th digit codes within range. 2. List the most specific code up to the 4 th or 5 th digit as applicable. (Truncated diagnosis codes are not acceptable.) 3. ICD-9 codes with limited coverage are listed per applicable CPT codes SYPHILITIC ACOUSTIC NEURITIS MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES - MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE BENIGN NEOPLASM OF CRANIAL NERVES NEUROFIBROMATOSIS TYPE 2 ACOUSTIC NEUROFIBROMATOSIS SCHWANNOMATOSIS OTHER NEUROFIBROMATOSIS

12 Page 12 of NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED PARTS OF NERVOUS SYSTEM NEOPLASM OF UNSPECIFIED NATURE OF BRAIN CONVERSION DISORDER OTHER SPECIFIC DEVELOPMENTAL LEARNING DIFFICULTIES SPEECH AND LANGUAGE DEVELOPMENTAL DELAY DUE TO HEARING LOSS HEMOPHILUS MENINGITIS - MENINGITIS DUE TO UNSPECIFIED BACTERIUM CRYPTOCOCCAL MENINGITIS - MENINGITIS DUE TO OTHER NONBACTERIAL ORGANISMS CLASSIFIED ELSEWHERE NONPYOGENIC MENINGITIS - MENINGITIS UNSPECIFIED ENCEPHALITIS AND ENCEPHALOMYELITIS IN VIRAL DISEASES CLASSIFIED ELSEWHERE - UNSPECIFIED CAUSES OF ENCEPHALITIS, MYELITIS, AND ENCEPHALOMYELITIS OTHER DEGENERATIVE DISEASES OF THE BASAL GANGLIA ESSENTIAL AND OTHER SPECIFIED FORMS OF TREMOR MYOCLONUS TICS OF ORGANIC ORIGIN HUNTINGTON'S CHOREA OTHER CHOREAS GENETIC TORSION DYSTONIA BLEPHAROSPASM OROFACIAL DYSKINESIA SPASMODIC TORTICOLLIS ORGANIC WRITERS' CRAMP SUBACUTE DYSKINESIA DUE TO DRUGS UNSPECIFIED EXTRAPYRAMIDAL DISEASE AND ABNORMAL MOVEMENT DISORDER STIFF-MAN SYNDROME NEUROLEPTIC MALIGNANT SYNDROME

13 Page 13 of BENIGN SHUDDERING ATTACKS OTHER EXTRAPYRAMIDAL DISEASES AND ABNORMAL MOVEMENT DISORDERS 340 MULTIPLE SCLEROSIS NEUROMYELITIS OPTICA SCHILDER'S DISEASE ACUTE (TRANSVERSE) MYELITIS NOS ACUTE (TRANSVERSE) MYELITIS IN CONDITIONS CLASSIFIED ELSEWHERE IDIOPATHIC TRANSVERSE MYELITIS OTHER DEMYELINATING DISEASES OF CENTRAL NERVOUS SYSTEM DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED BELL'S PALSY OPTIC NEURITIS UNSPECIFIED - OTHER OPTIC NEURITIS PERICHONDRITIS OF PINNA UNSPECIFIED - CHRONIC PERICHONDRITIS OF PINNA CHONDRITIS OF PINNA HEMATOMA OF AURICLE OR PINNA IMPACTED CERUMEN ACQUIRED STENOSIS OF EXTERNAL EAR CANAL UNSPECIFIED AS TO CAUSE - ACQUIRED STENOSIS OF EXTERNAL EAR CANAL SECONDARY TO INFLAMMATION EXOSTOSIS OF EXTERNAL EAR CANAL ACUTE NONSUPPURATIVE OTITIS MEDIA UNSPECIFIED - DYSFUNCTION OF EUSTACHIAN TUBE ACUTE SUPPURATIVE OTITIS MEDIA WITHOUT SPONTANEOUS RUPTURE OF EARDRUM - UNSPECIFIED OTITIS MEDIA ACUTE MASTOIDITIS WITHOUT COMPLICATIONS - UNSPECIFIED MASTOIDITIS ACUTE MYRINGITIS UNSPECIFIED - UNSPECIFIED DISORDER OF TYMPANIC MEMBRANE

14 Page 14 of TYMPANOSCLEROSIS UNSPECIFIED AS TO INVOLVEMENT - UNSPECIFIED DISORDER OF MIDDLE EAR AND MASTOID MÉNIÈRE'S DISEASE, UNSPECIFIED - INACTIVE MÉNIÈRE'S DISEASE PERIPHERAL VERTIGO UNSPECIFIED - OTHER PERIPHERAL VERTIGO VERTIGO OF CENTRAL ORIGIN LABYRINTHITIS UNSPECIFIED - VIRAL LABYRINTHITIS UNSPECIFIED VERTIGINOUS SYNDROMES AND LABYRINTHINE DISORDERS OTOSCLEROSIS INVOLVING OVAL WINDOW NONOBLITERATIVE - OTOSCLEROSIS UNSPECIFIED DEGENERATIVE AND VASCULAR DISORDERS UNSPECIFIED TRANSIENT ISCHEMIC DEAFNESS NOISE EFFECTS ON INNER EAR UNSPECIFIED - NOISE-INDUCED HEARING LOSS SUDDEN HEARING LOSS UNSPECIFIED TINNITUS UNSPECIFIED - OBJECTIVE TINNITUS ABNORMAL AUDITORY PERCEPTION UNSPECIFIED - ACQUIRED AUDITORY PROCESSING DISORDER DISORDERS OF ACOUSTIC NERVE OTORRHEA UNSPECIFIED - OTHER OTORRHEA OTALGIA UNSPECIFIED OTOGENIC PAIN CONDUCTIVE HEARING LOSS UNSPECIFIED - CONDUCTIVE HEARING LOSS OF COMBINED TYPES SENSORINEURAL HEARING LOSS UNSPECIFIED - SENSORINEURAL HEARING LOSS, BILATERAL MIXED HEARING LOSS, UNSPECIFIED MIXED HEARING LOSS, UNILATERAL MIXED HEARING LOSS, BILATERAL OTHER SPECIFIED FORMS OF HEARING LOSS

15 Page 15 of UNSPECIFIED HEARING LOSS DIZZINESS AND GIDDINESS ABNORMAL INVOLUNTARY MOVEMENTS COGNITIVE COMMUNICATION DEFICIT INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITHOUT OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED - INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED INJURY TO FACIAL NERVE - INJURY TO ACOUSTIC NERVE E930.3 ERYTHROMYCIN AND OTHER MACROLIDES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE E935.3 SALICYLATES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE V58.11 ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY V58.12 ENCOUNTER FOR IMMUNOTHERAPY FOR NEOPLASTIC CONDITION V58.62 LONG-TERM (CURRENT) USE OF ANTIBIOTICS V66.2 CONVALESCENCE FOLLOWING CHEMOTHERAPY V67.51 FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT ELSEWHERE CLASSIFIED V72.12 ENCOUNTER FOR HEARING CONSERVATION AND TREATMENT Medical Necessity for Audiometry to monitor auditory manifestations of HIV infection is limited to CPT Code and must include the following ICD-9 code: 042 HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE Medical necessity for audiometric testing related to behavioral problems is limited to CPT code and must include the following ICD-9 code: V71.02 OBSERVATION OF CHILDHOOD OR ADOLESCENT ANTISOCIAL BEHAVIOR Medical Necessity for CPT codes 92582, (Conditioning play audiometry and select picture audiometry) is supported for the following diagnoses. NOTE: Screening is not covered MILD INTELLECTUAL DISABILITIES - UNSPECIFIED INTELLECTUAL DISABILITIES Medical Necessity for CPT codes 92601, 92602, 92603, (services following cochlear implant) is supported for the following ICD-9 codes. NOTE: Must include the V53.09 AND either or

16 Page 16 of SENSORINEURAL HEARING LOSS UNSPECIFIED SENSORINEURAL HEARING LOSS, BILATERAL V53.09 FITTING AND ADJUSTMENT OF OTHER DEVICES RELATED TO NERVOUS SYSTEM AND SPECIAL SENSES Diagnoses that Support Medical Necessity Not Applicable ICD-9 Codes that DO NOT Support Medical Necessity PRESBYACUSIS V53.2 FITTING AND ADJUSTMENT OF HEARING AID V72.11 ENCOUNTER FOR HEARING EXAMINATION FOLLOWING FAILED HEARING SCREENING V72.19 OTHER EXAMINATION OF EARS AND HEARING ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation Diagnoses that DO NOT Support Medical Necessity Not Applicable Back to Top General Information Documentations Requirements A. Documentation (i.e. ICD-9 Codes) supporting the medical necessity of audiological testing must be submitted with each claim. Claims submitted without such evidence will be denied as being not medically necessary. B. Documentation that must be maintained in the patient's record and available upon request includes (but is not limited to): Diagnostic audiological examination report Physician order Diagnosis Patient history and physical information Additional diagnostic studies that support and justify the need for diagnostic audiology testing Patient referral information Consultation report related to hearing problems Sufficient information to support that the services rendered were reasonable and necessary

17 Page 17 of 23 C. Documentation supporting the audiologist's credentials must be maintained in the provider's office and made available to Medicare upon request. A qualified audiologist is a person who, by virtue of academic degree, clinical training, and license to practice and/or professional credential, is uniquely qualified to provide a comprehensive array of professional services related to the assessment and habilitation/ rehabilitation of persons with auditory and vestibular impairments, and to the prevention of these impairments. Appendices A. Reasons for Denial: 1. Claims that lack the necessary information to process the claim. 2. Claims submitted without a covered ICD-9 diagnosis. 3. Claims submitted with a noncovered ICD-9 diagnosis. 4. Services denied as excluded under 1862(a)(7) of the Act include: Duplicative services, i.e. when the diagnostic information required to determine the appropriate medical or surgical treatment is already known to the physician. When the diagnostic services are performed only to determine the need for or the appropriate type of a hearing aid. Routine hearing aid evaluations (screenings). Fitting/repairing of hearing aids. 5. Routine examinations performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury such as screenings or examinations required for third parties such as insurance companies, business establishments or government agencies. 6. Self referred examinations; Claims submitted without a NPI (National Provider Identifier) and name in FL76 are presumed to be for services provided as a result of self-referral. 7. Services not generally accepted as standard of care. 8. Non-covered services. These include, but are not limited to: Evaluations related to chronic tinnitus or chronic vertigo. Cochleostomy with neurovascular transplant for Meniere's Disease. Tinnitus masking. Oxygen treatment of inner ear/carbon therapy. Sedated auditory brainstem response (ABR) testing for the developmentally delayed in the absence of significant clinical finding or appropriate medical justification.

18 Page 18 of 23 Screening audiometry. Services provided by nonqualified staff. CPT codes and 92508: treatment of auditory processing disorders or auditory rehabilitation/auditory training (including speech-reading or lipreading. These codes always represent speech language pathology (SLP) services. These SLP evaluation and treatment services are not covered when performed or billed by audiologists, even if they are supervised by physicians or qualified NPPs. 9. Claims with modifier 50 will be returned to the provider. Utilization Guidelines Not Applicable Sources of Information and Basis for Decision Audiology: Scope of Practice; American Academy of Audiology. Available at: aspx. Daly KA, Hunter LL, Giebink GS. Chronic Otitis Media with Effusion. Pediatrics in Review. 1999;20(3): Baylor College of Medicine, Core Curriculum Syllabus. Audiology. Accessed at BCM Otolaryngology Home Page on 05/05/2003. Available at: Tobin H, Baquet GM, Koslowski JA. Evaluation Procedures. In: Rehabilitation Research and Development Service Practical Hearing Aid Selection and Fitting.1999: Saunders G. Other Evaluative Procedures. In: Rehabilitation Research and Development Service Practical Hearing Aid Selection and Fitting.1999: Beaubien AR, Desjardins S, Ormsby E, et al. Delay in Hearing Loss Following Drug Administration: A Consistent Feature of Amikacin Ototoxicity. Acta Otolaryngol. 1990;109 (5-6): Other Medicare contractors, specialty societies, and specialty consultants. NOTE: Some of the websites used to create this policy may no longer be available. Advisory Committee Meeting Notes This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which include representatives from the affected provider community. Contractor Advisory Committee meeting dates: California - Hawaii - Nevada - Start Date of Comment Period End Date of Comment Period

19 Page 19 of 23 Start Date of Notice Period 06/16/2008 Revision History Number Revision #12, 02/16/2012 Revision History Explanation Revision #12, 02/16/2012 Under CMS National Coverage Policy corrected the word an to now read a in the first paragraph. Under Indications and Limitations of Coverage and/or Medical Necessity #4B. PIPB (Performance Intensity Function of Phonetically Balanced Words) Functions changed the word of to for. Under Indications and Limitations of Coverage and/or Medical Necessity #4J. Staggered spondaic word test (92572) in the last sentence of the paragraph the word in was corrected to now read is. Under Indications and Limitations of Coverage and/or Medical Necessity #4R. the CPT description was corrected for CPT and Under CPT/HCPCS Codes added the NOTE for emphasis. CPT code was added to the list of non-covered procedures when used as a screening. Under Sources of Information and Basis for Decision the url was corrected for the following citation: Audiology: Scope of Practice; American Academy of Audiology. Available at: aspx. The references were placed in the AMA citation format. The LCD and accompanying coding guidelines article were reviewed for annual validation. This revision becomes effective 02/16/2012. Revision #11, 01/01/2012 Under Indications and Limitations of Coverage and/or Medical Necessity-R. the verbiage was revised for CPT codes and Under CPT/HCPCS Codes the code descriptions were revised for 92587, 92588, and This revision was due to the 2012 Annual CPT/HCPCS Update. This revision becomes effective 01/01/2012. Revision #10, 01/21/2011 Under Indications and Limitations of Coverage and/or Medical Necessity-4. Diagnostic Audiometry-O. Conditioning Play Audiometry the acronym was corrected to now read "CPA." Under Indications and Limitations of Coverage and/or Medical Necessity-4. Diagnostic Audiometry-Q. added the definition for ABR. Under Sources of Information and Basis for Decision the url was corrected for the following reference:baylor College of Medicine, Core Curriculum Syllabus. Audiology. Accessed at BCM Otolaryngology Home Page on 05/05/2003. Under Sources of Information and Basis for Decision the NOTE was added. This LCD and the accompanying supplemental instructions article were reviewed for annual validation. This revision becomes effective 01/21/2011. Revision #9, 01/01/2011 Under Indications and Limitations of Coverage and/or Medical Necessity under 3B in the first bullet corrected the code description for CPT code and under the fourth bullet added the verbiage "impedance testing" for CPT code Under 4R corrected the verbiage for CPT code Under #3 after the paragraph, "Audiology tests are covered as other diagnostic tests... corrected the heading to read "Audiologic Function Tests." This revision was due to the 2011 CPT/HCPCS Annual Update. This revision becomes effective 01/01/2011. Revision #8, 10/21/2010 Under CMS National Coverage Policy deleted Change Requests Transmittals 129 and 2007 as this information was manualized. The titles were corrected for the following manual citations: CMS Manual System, Pub , Medicare Benefit Policy Manual, Chapter 15, 80.3 CMS Manual System, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part and 50.6 CMS Manual System, Pub , Medicare Claims Processing Manual, Chapter 6,

20 Page 20 of CMS Manual System, Pub , Medicare Claims Processing Manual, Chapter 12, 30.3 This revision becomes effective 10/21/2010. Revision #7, 10/01/2010 Under Bill Type Codes the code description was revised for 012X, 013X, 018X, 021X, 022X, 023X, and 085X. Under Revenue Codes the code description was revised for These revisions were implemented due to updates of the National Uniform Billing Committee (NUBC) e-manual and were effective 08/01/2010. Under CMS National Coverage Policy corrected the transmittal numbers and effective dates for Change Request 6447 to now read: CMS Manual System, Pub , Medicare Benefit Policy Manual, Transmittal 129, dated July 23, 2010, Change Request 6447 and CMS Manual System, Pub , Medicare Claims Processing Manual, Transmittal 2007, dated July 23, 2010, Change Request Under ICD-9 Codes that Support Medical Necessity added , and This LCD is being revised due to the annual FY 2011 ICD-9-CM code update. This revision will become effective 10/01/2010. Revision #6, 07/28/2010 Under CMS National Coverage Policy added the following: CMS Manual System, Pub , Medicare Benefit Policy Manual, Transmittal 127, dated May 28, 2010, Change Request 6447 and CMS Manual System, Pub , Medicare Claims Processing Manual, Transmittal 1975, dated May 28, 2010, Change Request Under Indications and Limitations of Coverage and/or Medical Necessity-Audiometry deleted #3- Comprehensive audiometry threshold evaluation and speech recognition (92557) as this language was removed from Pub , Medicare Claims Processing Manual, Chapter 12, The subheadings under Audiometry were renumbered. Under Diagnostic Audiometry - C. Bekesy Audiometry; diagnostic deleted the verbiage regarding computerized testing devices as this language was removed from Pub , Medicare Claims Processing Manual, Chapter 12, Under Diagnostic Audiometry - S. Evaluation of auditory rehabilitation status; first hour (92626) or each additional 15 minutes (92627) the verbiage in the first and second paragraph was revised to be consistent with the quoted manual verbiage. Under Diagnostic Audiometry - S. Evaluation of auditory rehabilitation status; first hour (92626) or each additional 15 minutes (92627) in the second paragraph #1 added the word, related. Under Documentation Requirements B. added the last bullet. Under Appendices #8 - Noncovered Services deleted the 8th bullet titled Otograms as this language was removed from Pub , Medicare Claims Processing Manual, Chapter 12, Under Appendices #9- CPT Codes and the verbiage was revised to be consistent with the quoted manual verbiage. Under Appendices statement #10 was deleted as this language was removed from Pub , Medicare Claims Processing Manual, Chapter 12, Under Sources of Information and Basis for Decision the references were placed in the AMA citation format. This revision becomes effective 07/28/2010. Revision #5, 01/28/2010 Under CMS National Coverage Policy added the 1st paragraph. Under Indications and Limitations of Coverage and/or Medical Necessity- Pure Tone Audiometry added "threshold". Under Speech Audiometry added "threshold" and revised A and B to read as complete sentences. Under Comprehensive audiometry threshold evaluation and speech recognition added CPT code in the title. Under Immittance Audiometry revised A and B to read as complete sentences. Under Tympanometry (92567) added "impedance testing". Under Acoustic Immittance Testing (92570) added the CPT code for acoustic reflex threshold testing Under Filtered speech test (92571) added "a" to the last sentence. Under Appendices #6 revised "UPIN" to now read "NPI (National Provider

21 Page 21 of 23 Identifier)" and changed "FL 82" to now read "FL 76". Under Sources of Information and Basis for Decision revised the url for Evaluation Procedures. Deleted the following source, "Medicine, post -cochlear implant training, 92510" as this CPT code was deleted. The references were placed in the AMA citation format. This LCD was reviewed for annual validation. This revision becomes effective 01/28/2010. Revision #4, 01/01/2010 Under Indications and Limitations of Coverage and/or Medical Necessity-Immittance Audiometry added CPT code with description verbiage. CPT code was deleted with the accompanying description verbiage and CPT code with the accompanying verbiage was added. Under Indications and Limitations of Coverage and/or Medical Necessity-Diagnostic Audiometry-H. Acoustic reflex testing, threshold the description verbiage was revised. Under Indications and Limitations of Coverage and/or Medical Necessity-#3-Audiologic Testing deleted CPT code Under CPT/HCPCS Codes added CPT codes and CPT code was deleted. The descriptor verbiage was changed for CPT code This revision was due to the 2010 CPT/HCPCS Code Annual Update. This revision becomes effective 01/01/2010. Revision #3, 01/29/2009 Under CMS National Coverage Policy added the CMS manual reference: CMS Manual System, Pub , Medicare Claims Processing Manual, Chapter 12, 30.3 and deleted Change Request Under Indications and Limitations of Coverage and/or Medical Necessity corrected a typographical error for the 3rd paragraph regarding covered audiology services. The CPT code was corrected to read The verbiage for Pure Tone Audiogram was changed to read to Pure Tone Audiometry. Added the last sentence to #3-comprehensive auditory threshold evaluation and speech recognition regarding CPT code Throughout this section the verbiage for the CPT codes was corrected. Under 5. C added verbiage regarding computerized testing devices. Under S. added verbiage regarding CPT codes and Under CPT/HCPCS Codes-Audiologic Function Tests with medical diagnostic evaluation added CPT codes and Under Non-Covered Procedures added CPT codes and as per Change Request 6061, now found in the CMS Manual System, Pub , Medicare Claims Processing Manual, Chapter 12, Under Services following Cochlear Implant deleted CPT code 92507; this code is now found under Non- Covered Procedures. Under ICD-9 Codes That Support Medical Necessity deleted CPT code found in the section- Medical Necessity for CPT codes 92601, 92602, 92603, and (services following cochlear implants). Under Appendices added the last two bullets to #8- Non-covered services regarding otograms and CPT codes and Added #10 under Appendices-Reasons for Denial. The Coding Guidelines were moved to be an attached article to the LCD. Under Sources of Information and Basis for Decision the references were placed in the AMA citation format. This revision becomes effective 01/29/2009. Revision #2, 10/01/2008 This LCD is being revised due to the annual FY 2009 ICD-9 CM code update. Under CMS National Coverage Policy added 50.5 and 50.7 to CMS Manual System, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part 1. Revised verbiage for manual citations. Under Coverage Topic deleted "Lab Services" as this was not applicable to the LCD. Under Bill Type Codes deleted bill types 11X and 14X as these were not applicable to the LCD. Under ICD-9 Codes That Support Medical Necessity, the verbiage was revised for ICD-9 codes Under Appendices deleted references to cited statute and manual citations as these can be found under CMS National Coverage Policy. Under Sources of Information and Basis for Decision the references were placed in the AMA citation format. This revision becomes effective 10/01/2008. Revision #1, 08/20/2008

22 Page 22 of 23 Changed the Original Determination Effective Date from to to comply with the date change of the J1 A/B MAC, Part A cutover date. 04/19/ Adding contractor number in accordance with the J1 WPS transition. 8/1/ The description for Bill Type Code 12 was changed 8/1/ The description for Bill Type Code 13 was changed 8/1/ The description for Bill Type Code 18 was changed 8/1/ The description for Bill Type Code 21 was changed 8/1/ The description for Bill Type Code 22 was changed 8/1/ The description for Bill Type Code 23 was changed 8/1/ The description for Bill Type Code 85 was changed 8/1/ The description for Revenue code 0470 was changed 11/21/ For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document: descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group 4 08/27/ This policy was updated by the ICD Annual Update. 11/21/ For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document: descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group 4 Reason for Change Maintenance (annual review with new changes, formatting, etc.) Narrative Change Other Typographical Correction Related Documents Article(s) A Coding Guidelines for Audiological Testing; Audiological Services LCD Attachments

23 Page 23 of 23 There are no attachments for this LCD. Back to Top All Versions Updated on 02/08/2012 with effective dates 02/16/ N/A Updated on 12/16/2011 with effective dates 01/01/ /15/2012 Updated on 11/21/2011 with effective dates 01/21/ /31/2011 Updated on 08/27/2011 with effective dates 01/21/ N/A Updated on 02/11/2011 with effective dates 01/21/ N/A Updated on 01/14/2011 with effective dates 01/21/ N/A Updated on 11/23/2010 with effective dates 01/01/ /20/2011 Updated on 11/21/2010 with effective dates 10/21/ /31/2010 Updated on 10/15/2010 with effective dates 10/21/ N/A Some older versions have been archived. Please visit the MCD Archive Site them. to retrieve Read the LCD Disclaimer Back to Top Department of Health & Human Services Medicare.gov USA.gov Web Policies & Important Links Privacy Policy Freedom of Information Act No Fear Act Centers for Medicare & Medicaid Services, 7500 Security Boulevard Baltimore, MD