LCD for Audiology and Vestibular Function Tests (L23482)

 

Contractor Information

Contractor Name 

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator) 

Contractor Number 

00390 

Contractor Type 

FI 

 

LCD Information

LCD ID Number 

L23482 

 

LCD Title 

Audiology and Vestibular Function Tests 

 

Contractor's Determination Number 

L23482 

 

AMA CPT / ADA CDT Copyright Statement 

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.  

 

CMS National Coverage Policy 

Medicare Benefit Policy Manual - Pub. 100-2
--- Chapter 15, Section 80.3
Medicare National Coverage Determinations Manual - Pub. 100-3
Correct Coding Initiative - Medicare Contractor Beneficiary and Provider Communications Manual - Pub. 100-9, Chapter 5
Social Security Act (Title XVIII) Standard References
--- Section 1862 (a)(1)(A) Medically Reasonable & Necessary
--- Section 1862 (a)(1)(D) Investigational or Experimental
--- Section 1862 (a)(7) Screening (Routine Physical Checkups)
 

 

Primary Geographic Jurisdiction 

New Jersey
Tennessee
 

 

Secondary Geographic Jurisdiction 

Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
North Carolina
North Dakota
Nebraska
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
 

 

Oversight Region 

Region IV
 

 

 

Original Determination Effective Date 

For services performed on or after 09/30/2006  

 

Original Determination Ending Date 

 

 

Revision Effective Date 

For services performed on or after 11/18/2006  

 

Revision Ending Date 

 

 

Indications and Limitations of Coverage and/or Medical Necessity 

Vestibular tests are tests of function. Their purpose is to determine if there is something wrong with the vestibular portion of the inner ear. If dizziness is not caused by the inner ear, it might be caused by the brain, by medical disorders such as low blood pressure or by psychological problems such as anxiety. Studies have documented that vestibular tests are more accurate than clinical examination in identifying inner ear disorders. Hearing pathway tests (audiometry, Auditory Brainstem Response (ABR), Electrocochleography (ECoG)) can also be used for the same purpose and are frequently combined with vestibular tests.

Diagnostic otologic evaluation services are performed to detect presence or absence of a hearing deficit and to identify the factors responsible for the deficit. The assessment of a deficit involves both physical and physiological measurements for appropriate diagnosis and referral.

Accurate assessment of hearing (audiometry) is vital to the diagnostic evaluation of patients with suspected otologic disorders for the determination of the underlying process, as well as in the planning of rehabilitation of hearing loss. Originally, audiometry was limited to the psychophysical measurement of the sensation of hearing; thus, patient cooperation was essential. However, other tests have been developed over the years that permit more objective assessment of hearing even in infants, small children, malingerers and hysterics.

Most humans hear sounds in the range of 20 to 20,000 Hz. Sensitivity varies as a function of frequency, with sounds in the middle frequencies being heard best. The ability to hear higher frequencies declines with age.

Basic Audiometry: Adequate testing requires an audiometer (device for presenting sounds to the patient at precisely controlled intensity), a sound proof environment, a competent audiologist and a cooperative patient. The standard testing battery may vary depending on purpose.

- Pure Tone Audiometry, Speech Audiometry, and Immittance Audiometry


A. Pure Tone Audiogram: 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. By convention, normal hearing levels are shown at the top of a graph; a decrease in hearing sensitivity is indicated by larger values of hearing level. Hearing level is plotted on a logarithmic decibel scale. Sounds are tested with presentation by air conduction (earphones) as well as bone conduction (skull vibrator). An air bone gap indicates a conductive component of hearing loss. A decrease in threshold sensitivity by bone conduction reflects a sensory or neural loss.

B. Speech Audiometry: These tests utilize spoken words and sentences rather than pure tones. Tests are designed to assess sensitivity (threshold) or understanding (intelligibility).

- Threshold - The level at which the patient can correctly repeat 50 percent of test materials: Phoneme-Balanced words (PB), synthetic sentences, etc.

- Intelligibility - By convention, the percentage of words or sentences a patient can correctly repeat when presented at supra-threshold levels.

- Provides information about hearing handicap. Problem may be worse than indicated by pure tone average (PTA) for the speech frequencies. Useful to determine candidacy for hearing aid.

- Very poor results, out of proportion to PTA, suggest probable retrocochlear cause of hearing loss.

C. Immittance Audiometry: These hearing tests utilize an electroacoustic immittance bridge. This device is designed to quantify the impedance (resistance to movement) of the conductive mechanism of the ear by bouncing a probe tone off the tympanic membrane and measuring the proportion of reflected sound. Impedance testing can measure either the impedance or admittance (the American Speech-Language-Hearing Association term that encompasses both is "immittance"). Typically, today’s equipment measures admittance. The purpose of the test is to assess middle ear integrity. Maximal reflection of sound occurs when the mechanism is very stiff, while a compliant system transmits more sound and reflects less. There are two principal applications of this device:

 


- Tympanometry: A tympanogram is a graphic representation of the relationship of external auditory canal air pressure to impedance; the latter is usually reported in terms of tone of its derivatives, compliance in arbitrary units. Pressure in the external auditory canal is varied from -200 daPa through +200 daPa while monitoring impedance. Impedance is the lowest (maximal compliance) when pressure in the canal equals pressure in the middle ear. Ears can be classified into three basic groups (Type A, Type B and Type C) on the basis of the configuration of the tympanogram.

- Acoustic Reflex (AR): Contraction of the stapedius muscle occurs with loud sounds, producing a measurable change in compliance.



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. PI-PB functions - Speech discrimination is plotted as a function of sound intensity. Normally, discrimination improves with intensity up to a maximal level, then plateaus. In eighth nerve disorders, discrimination often declines dramatically as intensity increases above the level yielding maximum performances.

C. Bekesy Audiometry - This test has a significant historical interest in the development of assessment of hearing. However, today it is used predominantly only in industrial and military hearing screening situations. 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.

D. Tone Decay Tests - Abnormal adaptation to a continuous tone is seen in retro-cochlear lesions.

E. Stenger Test - Performed to detect malingering of unilateral loss. If sound is presented to both ears, patient will deny hearing in the ear with the feigned loss. If sound is presented to the good ear at a suprathreshold level, simultaneous to a louder sound in the questionable ear, a malingerer will localize the sound to his ‘bad’ ear, and therefore deny hearing anything at all.

F. ABR - Evoked Auditory Brainstem Responses - Scalp electrodes measure electrical activity 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.

G. ECOG (Electrocochleography) - Electrical activity is measured from the promontory, and responses to a large number of clicks are averaged. These will be abnormal in eighth cranial nerve lesions and certain cochlear disorders.



Audiologist’s Services

Diagnostic testing, including hearing and balance assessment services, performed by a qualified audiologist is covered as "other diagnostic tests" under Section 1861(s)(3) of the Social Security Act. This type of testing can be allowed when a physician orders the tests to obtain information as part of his/her diagnostic evaluation or to determine the appropriate medical or surgical treatment of a hearing deficit or related medical problem. Payment for diagnostic services performed by a qualified audiologist is determined by the reason the tests were performed, rather than the final diagnosis or the patient’s condition.

The practice of the profession of audiology means the application of principles, methods and procedures of measurement, testing, evaluation, consultation, counseling, instruction and rehabilitation related to hearing, its disorders and related communication and impairments for the purpose of non-medical diagnosis, prevention, identification, amelioration or modification of such disorders and conditions in individuals and/or groups of individuals.

As provided in Section 1861(II)(3) of the Social Security Act, a qualified audiologist is an individual with a master’s degree or doctoral degree in audiology and who has a valid license issued by the state in which the services are rendered.

In addition to the above qualification criteria, the following requirements must also be met:


- The testing is ordered by a physician to obtain additional information to evaluate the need for or appropriate type of medical or surgical treatment for a hearing deficit or related medical problem even if the only outcome is the prescription of a hearing aid.

- The name of the physician ordering the testing is reported on the audiologist’s claim. For example, if a beneficiary undergoes diagnostic testing performed by an audiologist without a physician’s referral, these tests are not covered even if the audiologist discovers a pathologic condition.



Indications


- Vestibular function tests and/or diagnostic audiometric tests are covered when testing is for the purpose of determining the appropriate medical or surgical treatment for disorders of auditory, balance and other neural systems.

- 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.

- Audiologic testing (CPT codes 92553, 92557, 92568, 92569) may be performed for patients on continuing (current) long-term (more than 14 days) use of antibiotics known to be ototoxic, such as streptomycin and aminoglycosides.

- If a physician refers a beneficiary to an audiologist for evaluation of signs and symptoms associated with hearing loss or ear injury, the audiologist’s diagnostic services are covered, even if the only outcome is the prescription of a hearing aid. It is the intent of the evaluation (identification or exclusion of pathology) not the outcome that determines medical necessity.


Limitations

- Screening evaluation or testing for hearing aid evaluation is specifically excluded by statute.

- Services are excluded under Section 1862(a)(7) of the Social Security Act when the diagnostic information required to determine the appropriate medical or surgical treatment is already known to the physician or are not under consideration and the diagnostic services are performed only to determine the need for the appropriate type of hearing aid. These services are excluded from Medicare coverage whether performed by a physician or non-physician; they are both statutorily excluded and not medically necessary.

- If a beneficiary undergoes diagnostic testing performed by an audiologist without a physician’s referral, these tests will not be covered even if the audiologist discovers a pathologic condition. These services are both statutorily excluded and not medically necessary.
 

 

Coverage Topic 

Diagnostic Tests and X-Rays
 

 

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.

12x

Hospital-inpatient or home health visits (Part B only)

13x

Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00)

18x

Hospital-swing beds

21x

SNF-inpatient, Part A

22x

SNF-inpatient or home health visits (Part B only)

23x

SNF-outpatient (HHA-A also)

28x

SNF-swing beds

71x

Clinic-rural health

73x

Clinic-independent provider based FQHC (eff 10/91)

85x

Special facility or ASC surgery-rural primary care hospital (eff 10/94)

 

 

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.

 

047X

Audiology-general classification

 

 

CPT/HCPCS Codes 

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.

92541

Spontaneous nystagmus test

92542

Positional nystagmus test

92543

Caloric vestibular test

92544

Optokinetic nystagmus test

92545

Oscillating tracking test

92546

Sinusoidal rotational test

92547

Supplemental electrical test

92552

Pure tone audiometry, air

92553

Audiometry, air & bone

92555

Speech threshold audiometry

92556

Speech audiometry, complete

92557

Comprehensive hearing test

92561

Bekesy audiometry, diagnosis

92562

Loudness balance test

92563

Tone decay hearing test

92564

Sisi hearing test

92565

Stenger test, pure tone

92567

Tympanometry

92568

Acoustic refl threshold tst

92569

Acoustic reflex decay test

92571

Filtered speech hearing test

92572

Staggered spondaic word test

92575

Sensorineural acuity test

92576

Synthetic sentence test

92577

Stenger test, speech

92579

Visual audiometry (vra)

92582

Conditioning play audiometry

92583

Select picture audiometry

92584

Electrocochleography

92585

Auditor evoke potent, compre

92586

Auditor evoke potent, limit

92587

Evoked auditory test

92588

Evoked auditory test

92596

Ear protector evaluation

92597

Oral speech device eval

92620

Auditory function, 60 min

92621

Auditory function, + 15 min

 

 

ICD-9 Codes that Support Medical Necessity 

The CPT/HCPCS codes included in this policy will be subjected to "procedure to diagnosis" editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as "not medically necessary."

Medicare is establishing the following limited coverage for CPT/HCPCS codes 92541, 92542, 92543, 92544, 92545, 92546 and 92547:

386.00 - 386.04

MENIERE'S DISEASE UNSPECIFIED - INACTIVE MENIERE'S DISEASE

386.10 - 386.12

PERIPHERAL VERTIGO UNSPECIFIED - VESTIBULAR NEURONITIS

386.19

OTHER PERIPHERAL VERTIGO

386.2

VERTIGO OF CENTRAL ORIGIN

386.30 - 386.35

LABYRINTHITIS UNSPECIFIED - VIRAL LABYRINTHITIS

386.40 - 386.43

LABYRINTHINE FISTULA UNSPECIFIED - SEMICIRCULAR CANAL FISTULA

386.48

LABYRINTHINE FISTULA OF COMBINED SITES

386.50 - 386.56

LABYRINTHINE DYSFUNCTION UNSPECIFIED - LOSS OF LABYRINTHINE REACTIVITY BILATERAL

386.58

OTHER FORMS AND COMBINATIONS OF LABYRINTHINE DYSFUNCTION

386.8 - 386.9

OTHER DISORDERS OF LABYRINTH - UNSPECIFIED VERTIGINOUS SYNDROMES AND LABYRINTHINE DISORDERS

389.10 - 389.12

SENSORINEURAL HEARING LOSS UNSPECIFIED - NEURAL HEARING LOSS, BILATERAL

389.14

CENTRAL HEARING LOSS

389.18

SENSORINEURAL HEARING LOSS, BILATERAL

Medicare is establishing the following limited coverage for CPT/HCPCS codes 92552, 92553, 92557, 92567, 92568 and 92569:

225.1

BENIGN NEOPLASM OF CRANIAL NERVES

300.11

CONVERSION DISORDER

381.00 - 381.06

ACUTE NONSUPPURATIVE OTITIS MEDIA UNSPECIFIED - ACUTE ALLERGIC SANGUINOUS OTITIS MEDIA

381.10

CHRONIC SEROUS OTITIS MEDIA SIMPLE OR UNSPECIFIED

381.19

OTHER CHRONIC SEROUS OTITIS MEDIA

381.20

CHRONIC MUCOID OTITIS MEDIA SIMPLE OR UNSPECIFIED

381.29

OTHER CHRONIC MUCOID OTITIS MEDIA

381.3 - 381.4

OTHER AND UNSPECIFIED CHRONIC NONSUPPURATIVE OTITIS MEDIA - NONSUPPURATIVE OTITIS MEDIA NOT SPECIFIED AS ACUTE OR CHRONIC

381.50 - 381.52

EUSTACHIAN SALPINGITIS UNSPECIFIED - CHRONIC EUSTACHIAN SALPINGITIS

381.60 - 381.63

OBSTRUCTION OF EUSTACHIAN TUBE UNSPECIFIED - EXTRINSIC CARTILAGENOUS OBSTRUCTION OF EUSTACHIAN TUBE

381.7

PATULOUS EUSTACHIAN TUBE

381.81

DYSFUNCTION OF EUSTACHIAN TUBE

381.89

OTHER DISORDERS OF EUSTACHIAN TUBE

381.9

UNSPECIFIED EUSTACHIAN TUBE DISORDER

382.00 - 382.02

ACUTE SUPPURATIVE OTITIS MEDIA WITHOUT SPONTANEOUS RUPTURE OF EARDRUM - ACUTE SUPPURATIVE OTITIS MEDIA IN DISEASES CLASSIFIED ELSEWHERE

382.1 - 382.4

CHRONIC TUBOTYMPANIC SUPPURATIVE OTITIS MEDIA - UNSPECIFIED SUPPURATIVE OTITIS MEDIA

382.9

UNSPECIFIED OTITIS MEDIA

384.20 - 384.25

PERFORATION OF TYMPANIC MEMBRANE UNSPECIFIED - TOTAL PERFORATION OF TYMPANIC MEMBRANE

385.00 - 385.03

TYMPANOSCLEROSIS UNSPECIFIED AS TO INVOLVEMENT - TYMPANOSCLEROSIS INVOLVING TYMPANIC MEMBRANE EAR OSSICLES AND MIDDLE EAR

385.09

TYMPANOSCLEROSIS INVOLVING OTHER COMBINATION OF STRUCTURES

385.10 - 385.13

ADHESIVE MIDDLE EAR DISEASE UNSPECIFIED AS TO INVOLVEMENT - ADHESIONS OF DRUM HEAD TO PROMONTORIUM

385.19

OTHER MIDDLE EAR ADHESIONS AND COMBINATIONS

385.22 - 385.23

IMPAIRED MOBILITY OF OTHER EAR OSSICLES - DISCONTINUITY OR DISLOCATION OF EAR OSSICLES

385.30 - 385.33

CHOLESTEATOMA UNSPECIFIED - CHOLESTEATOMA OF MIDDLE EAR AND MASTOID

385.35

DIFFUSE CHOLESTEATOSIS OF MIDDLE EAR AND MASTOID

386.00 - 386.04

MENIERE'S DISEASE UNSPECIFIED - INACTIVE MENIERE'S DISEASE

386.10 - 386.12

PERIPHERAL VERTIGO UNSPECIFIED - VESTIBULAR NEURONITIS

386.19

OTHER PERIPHERAL VERTIGO

386.2

VERTIGO OF CENTRAL ORIGIN

386.30 - 386.35

LABYRINTHITIS UNSPECIFIED - VIRAL LABYRINTHITIS

386.40 - 386.43

LABYRINTHINE FISTULA UNSPECIFIED - SEMICIRCULAR CANAL FISTULA

386.48

LABYRINTHINE FISTULA OF COMBINED SITES

386.50 - 386.56

LABYRINTHINE DYSFUNCTION UNSPECIFIED - LOSS OF LABYRINTHINE REACTIVITY BILATERAL

386.58

OTHER FORMS AND COMBINATIONS OF LABYRINTHINE DYSFUNCTION

386.8 - 386.9

OTHER DISORDERS OF LABYRINTH - UNSPECIFIED VERTIGINOUS SYNDROMES AND LABYRINTHINE DISORDERS

388.12

NOISE-INDUCED HEARING LOSS

388.2*

SUDDEN HEARING LOSS UNSPECIFIED

388.30 - 388.32

TINNITUS UNSPECIFIED - OBJECTIVE TINNITUS

389.10 - 389.12*

SENSORINEURAL HEARING LOSS UNSPECIFIED - NEURAL HEARING LOSS, BILATERAL

389.14*

CENTRAL HEARING LOSS

389.18*

SENSORINEURAL HEARING LOSS, BILATERAL

389.20

MIXED HEARING LOSS, UNSPECIFIED

389.21

MIXED HEARING LOSS, UNILATERAL

389.22

MIXED HEARING LOSS, BILATERAL

V58.62

LONG-TERM (CURRENT) USE OF ANTIBIOTICS

*Note: 388.2, 389.10 to 389.12, 389.14, 389.18, 389.2 - Tests for these ICD-9-CM codes are covered only for an initial evaluation of a hearing problem.

Medicare is establishing the following limited coverage for CPT/HCPCS code 92561:

225.1

BENIGN NEOPLASM OF CRANIAL NERVES

388.2*

SUDDEN HEARING LOSS UNSPECIFIED

389.10 - 389.12*

SENSORINEURAL HEARING LOSS UNSPECIFIED - NEURAL HEARING LOSS, BILATERAL

389.14*

CENTRAL HEARING LOSS

389.18*

SENSORINEURAL HEARING LOSS, BILATERAL

389.20

MIXED HEARING LOSS, UNSPECIFIED

389.21

MIXED HEARING LOSS, UNILATERAL

389.22

MIXED HEARING LOSS, BILATERAL

*Note: 388.2, 389.10 to 389.12, 389.14, 389.18, 389.2 - Tests for these ICD-9-CM codes are covered only for an initial evaluation of a hearing problem.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 92562 and 92564:

386.00 - 386.03

MENIERE'S DISEASE UNSPECIFIED - ACTIVE MENIERE'S DISEASE VESTIBULAR