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Vestibular Evaluation for Dizziness Coding CPT

Vestibular Evaluation for Dizziness Coding CPT

Name That Code

Question:  A patient with complaints of dizziness is seen for a vestibular evaluation. The physician completed the following tests: spontaneous nystagmus with gaze; positional nystagmus in four positions; optokinetic nystagmus, bidirectional; and oscillating tracking. All the tests were performed using a recording device.

Assign for CPT.

Answer:

Answer: 92540

Vestibular Evaluation for Suspected Vestibular Disorder

A vestibular evaluation is an examination that is typically performed by an ear, nose, and throat (ENT) doctor, an audiologist, or an otolaryngologist. The evaluation is performed for nystagmus, which is a quick, involuntary movement of the eye. 

According to the Academy of Neurologic Physical Therapy, a patient with a suspected vestibular disorder, such as benign positional paroxysmal vertigo (BPPV) or vestibular migraine, may undergo an evaluation to determine the health of the vestibular portion of the inner ear and to rule out a brain disorder as the cause of dizziness, vertigo, and balance problems. 

Locate and Verify

Suppose we were to start by looking in the Index of CPT for the individual codes under spontaneous with gaze, optokinetic, positional, and oscillating tracking tests.

We would find:

  • Vestibular/function test/nystagmus/spontaneous, 92431, 92541
  • Vestibular/function test/nystagmus/optokinetic, 92534, 92544
  • .Vestibular/function test/nystagmus/positional, 92532, 92542
  • Vestibular/function test/tracking test, 92545

When we go to these codes in the Tabular, we can see the following descriptions for these codes:

  • 92531, Spontaneous nystagmus, including gaze
  • 92541, Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording
  • 92534, Optokinetic nystagmus test
  • 92544, Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording
  • 92532, Positional nystagmus test
  • 92542, Positional nystagmus test, minimum of 4 positions, with recording
  • 92545, Oscillating tracking test, with recording

With and Without Electrical Recording

In the Medicine section of the Tabular listing under Special Otorhinolaryngologic Services and Procedures, CPT codes 92531, 92532, and 92534 describe vestibular function tests without electrical recording.

CPT codes 92541, 92542, 92544, and 92545 describe vestibular function tests with recording.

Before we can report these four codes, however, we need to review the instructional notes provided at each code. For instance,

  • At 92541, the instructions state, “Do not report 92541 in conjunction with 92270, 92540 or the set of 92542, 92544, and 92545.”
  • At 92542, “Do not report 92542 in conjunction with 92270, 92540 or the set of 92541, 92544, and 92545).”
  • At 92544, “Do not report 92544 in conjunction with 92270, 92540 or the set of 92541, 92542, and 92545).”
  • At 92545, “Do not report 92545 in conjunction with 92270, 92540 or the set of 92541, 92542, and 92544.”

In other words, we cannot code 92541, 92542, 92544, and 92545 with codes 92270 and 92540. Instead, code 92540 should be assigned to indicate all four tests were performed as components of the vestibular evaluation.

CPT code 92270 refers to Electro-oculography with interpretation and report.

CPT Code 92540

The code description for 92540 is:

92540, Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording.

The instructional note at 92540 states, “Do not report 92540 in conjunction with 92270, 92541, 92542, 92544, 92545.”

As long as all 4 components are performed in their entirety during the same visit, CPT 92540 should be reported. If the documentation states all 4 components were not able to be done as part of the basic vestibular evaluation, the reason should be stated, and modifier 59 should be appended to each of the codes reported to indicate it was a distinct procedural service.

Video on Vestibular Function Tests

This short video (just over 2 minutes) shows vestibular function tests to help diagnose the cause of dizziness and imbalance.


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