Clarification On Use of Codes 92626 and 92627

November 20, 2015

Based upon questions that arose from some of the presentations at this year’s ADA Convention in Washington, DC, I have opted to re-publish some guidance on the appropriate use of 92626 and 92627 as well as the Medicare guidance on medical necessity.
 
Billing of 92626 and 92627
 
The content in this Q&A was compiled in collaboration with the Academy of Doctors of Audiology (ADA), the American Academy of Audiology (AAA), and the American Speech-Language-Hearing Association (ASHA).
 
There has been confusion regarding the appropriate use of Current Procedural Terminology (CPT ® American Medical Association) codes related to the evaluation of auditory rehabilitation status. The guidance below is based on an article, Coding Brief: Evaluation of Auditory Rehabilitation Status (92626), from the July 2014 edition of the CPT Assistant which is published by the American Medical Association and considered an authoritative source for coding guidance. These codes have coverage and non-coverage applications and audiologists will need to validate coverage with their individual payers.
 
The codes addressed in this article are: 
  • 92626 Evaluation of auditory rehabilitation status; first hour
  • 92627 Evaluation of auditory rehabilitation status; each additional 15 minutes 
When is it appropriate to use CPT codes 92626 and 92627?
 
Audiologists may report CPT codes 92626 and 92627 when evaluating the auditory function of a patient either before or after the patient receives unilateral or bilateral hearing devices, including:
  • hearing aid(s),
  • auditory osseo-integrated implant(s),
  • middle-ear implant(s),
  • cochlear implant(s), and/or
  • auditory brainstem implants. 
According to the CPT Assistant, the “evaluation will determine the need for auditory rehabilitation following the fitting and verification of hearing devices and may also be used to monitor the progress of therapeutic intervention.”
 
Do these codes capture other services related to hearing aids or cochlear implants?
 
No. The CPT Assistant is clear that it is inappropriate to use 92626 and 92627 for services other than the evaluation of auditory function to determine the need for rehabilitation. The items below provide guidance on appropriate coding for other commonly reported services related to hearing aids and cochlear implants:
  • Hearing aid examination and selection should be coded using 92590 (monaural), 92591 (binaural) or V5010.
  • Fitting, orientation, and checking of a hearing aid are reported using HCPCS code V5011.
  • Hearing aid checks are reported using 92592 or 92593.
  • Hearing aid verification and validation is reported using V5020.
  • Hearing aid dispensing fees are reported using one of the following HCPCS codes: V5090, V5110, V5160, V5200, V5240, or V5241.
  • Diagnostic analysis and programming/reprogramming services related to cochlear implants are reported with CPT codes 92601 through 92604.
  • Cochlear implant troubleshooting is reported using 92700 or L9900.
  • Aural rehabilitation is reported using 92630 or 92633.
  • Tinnitus evaluations are reported using 92625. 
When can I use 92626 and 92627 with commercial payers?
 
Commercial payers may have different policies on the medical necessity and coverage of the evaluation of aural rehabilitation status. Coverage policies may also vary for the same payer depending on the type of plan. Billing practices and coverage policies for these CPT codes should be verified with the commercial payer.
 
Can I use this code for patient and/or family counseling?
 
This is not considered an appropriate use of 92626 and 92627. The audiologist’s time spent in counseling is not separately reportable to Medicare. Audiologists should consult non-Medicare payers before separately coding for time spent counseling.
 
How do I bill these codes if the evaluation lasts more or less than an hour?
 
The CPT Assistant states that 92626 “is a time-based code and is reported for the first hour of evaluation. Code 92626 should not be reported for evaluations of auditory function lasting less than 31 minutes. Add-on code 92627 is reported for each additional 15 minutes of evaluation and must be used in conjunction with code 92626 for evaluations lasting longer than 60 minutes.”
 
“When reporting codes 92626 and 92627, the documented time spent face to face with the patient or family should be used to determine the length of the auditory rehabilitation evaluation.” It is important for providers to clearly document in the patient’s medical record the time spent providing the evaluation service (e.g. start and stop time). 
 
If the evaluation is 30 minutes or less can I report 92627 alone or report 92626 with the 52 modifier?
 
No, the add-on code 92627 cannot be billed independently of 92626 and cannot be used for instances when the documented time spent in evaluation is less than 31 minutes. The reduced service modifier (-52) cannot be used with any time-based procedure codes.
 
If the time spent for the evaluation is less than 30 minutes, 92700 (Unlisted otorhinolaryngological service or procedure) may be reported. However, when filing a claim including 92700, it will be necessary to submit supporting documentation detailing the need for the service, as well as the time, effort, and equipment necessary to provide the service.
 
In other words, 92626 and 92627 should not be billed for coverage, for traditional Medicare beneficiaries, for the evaluation of aural rehabilitation status for hearing aid users who are not being evaluated for an auditory prosthetic device such as a cochlear implant or osseointegrated device.  At this juncture, Medicare does not cover testing solely related to the selection, adjustment or modification of a hearing aid.
 
Medical Necessity
 
  • The Medicare Benefit Policy Manual, Chapter 15, section 80.3 (C)(http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf) has clearly defined what constitutes medical necessity. They state:
    • “Examples of appropriate reasons for ordering audiological diagnostic tests that could be covered include, but are not limited to:
      • Evaluation of suspected change in hearing, tinnitus, or balance;
      • Evaluation of the cause of disorders of hearing, tinnitus, or balance;
      • Determination of the effect of medication, surgery, or other treatment;
      • Reevaluation to follow-up changes in hearing, tinnitus, or balance that may be caused by established diagnoses that place the patient at probable risk for a change in status including, but not limited to:  otosclerosis, atelectatic tympanic membrane, tympanosclerosis, cholesteatoma, resolving middle ear infection, Meniére’s disease, sudden idiopathic sensorineural hearing loss, autoimmune inner ear disease, acoustic neuroma, demyelinating diseases, ototoxicity secondary to medications, or genetic vascular and viral conditions;
      • Failure of a screening test (although the screening test is not covered);
      • Diagnostic analysis of cochlear or brainstem implant and programming; and
      • Audiology diagnostic tests before and periodically after implantation of auditory prosthetic devices.
      • If a physician refers a beneficiary to an audiologist for testing related to signs or symptoms associated with hearing loss, balance disorder, tinnitus, ear disease, or ear injury, the audiologist’s diagnostic testing services should be covered even if the only outcome is the prescription of a hearing aid”
    • Medicare also stated:
      • “Under any Medicare payment system, payment for audiological diagnostic tests is not allowed by virtue of their exclusion from coverage in section 1862(a)(7) of the Social Security Act when:
        • The type and severity of the current hearing, tinnitus or balance status needed to determine the appropriate medical or surgical treatment is known to the physician before the test; or
        • The test was ordered for the specific purpose of fitting or modifying a hearing aid”.
  • The Medicare Benefit Policy Manual, Chapter 15, section 80.3 (E) (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf) states the following:
    • “The reason for the test should be documented either on the order, on the audiological evaluation report, or in the patient’s medical record”
    • “Documentation should indicate that the test was ordered, that the reason for the test results in coverage, and that the test was furnished to the patient by a qualified individual”
      • In reality, most physician orders do not specify the reason for the test and why that test results in coverage.
      • Also, as many of our members provide care in private or independent practices, there is no shared medical record available.
  • As a result, the rendering audiologist (the audiologist that performs the testing) must document in THEIR medical records (via a report and/or chart notes) why they did what they did FOR EACH PROCEDURE PROVIDED.
    • Audiologists need to document the medical necessity of each procedure they perform.
  • Just because a procedure was requested or ordered, that does not mean that it is medically necessary.
  • Payers, such as Medicare and Medicaid, do not cover standards of care, office protocols or “routine” or “annual” testing where medical necessity has not been met.
  • Be careful of the routine (more than 51% of your adult patients) performance of some of these procedures where you are seeking Medicare coverage.  It is important to ensure that medical necessity has been documented in the medical record.  Medicare and Medicaid programs have been auditing potential overutilization of these procedures/codes:
    • 92546: Rotation chair testing
    • 92548: Dynamic computerized posturography
    • 92550: Tympanometry and acoustic reflex threshold testing
    • 92567: Tympanometry
    • 92570: Tympanometry, acoustic reflex threshold testing, and acoustic reflex decay
    • 92587: Otoacoustic emissions, limited
    • 92588: Otoacoustic emissions, comprehensive
    • 92626: Evaluation of aural rehabilitation status
 
Please contact Kim Cavitt, AuD at kim.cavitt@audiologyresources.com with any additional questions or concerns.