Question:  A patient with complaints of dizziness is seen for a vestibular evaluation. The physician completed the following tests: spontaneous with gaze, optokinetic, oscillating tracking, positionals head right and left, and Dix-Hallpike right and left. The physician also completed warm and cool caloric irrigations in both ears, for a total of four irrigations. All tests were performed using a recording device.

Assign the appropriate CPT codes.

Answer:

92540, 92537

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 Therapya 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. 

To find the correct CPT codes, we can go to the Alphabetic Index of the CPT coding manual and look under Vestibular, function test, nystagmus: spontaneous, 92431, 92541; optokinetic, 92534, 92544; positional, 92532, 92542; tracking test, 92545.

In the Medicine section of the Tabular under Special Otorhinolaryngologic Services and Procedures, CPT codes 92531-92534 describe vestibular function tests without electrical recording. CPT codes for vestibular function tests with recording (e.g. ENG) are covered by codes 92537-92548.

The individual codes for the gaze, optokinetic, oscillating tracking tests, and positionals head right and left can be verified in the Tabular as:

  • 92541, spontaneous nystagmus test, including gaze and fixation nystagmus, with recording
  • 92544, optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording
  • 92545, oscillating tracking test, with recording
  • 92542, positional nystagmus test, minimum of four positions, with recording

But let’s look a little closer at CPT code 92542. The code description says a “minimum of 4 positions,” and in the scenario above, it indicates  “positionals head right and left” were performed. That’s 2 positions. We need 2 more positions to report 92542.

But, we have it!

The reason we can report 92542 is that a Dix-Hallpike maneuver right and left (2 positions) was also performed, making it a total of 4 positions. Dix-Hallpike does not have its own specific code and is generally considered part of the positional component. According to the National Center for Biotechnology Information (NCBI), the Dix-Hallpike maneuver involves the patient’s head being rotated and the physician observing the eyes for nystagmus.

So we have our 4 positions.

But wait!  

Before we can report these four codes (92541, 92542, 92544, and 92545), we need to review the CPT coding guidelines for each. The guidelines state each of these codes cannot be reported with codes 92270 or 92540. Furthermore, these four codes cannot be reported together in a set. Instead, there is a code that combines all of these tests into one code, which 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

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.

Our first code is CPT 92540. 

Continuing on…

Caloric irrigations, another vestibular function test, is verified in the Tabular as:

  • 92537, caloric vestibular test with recording, bilateral; bithermal (ie, one warm and one cool irrigation in each ear for a total of four irrigations)

Per the CPT coding guidelines, 92537 cannot be reported in conjunction with 92270 or 92538.

Coding guidelines further indicate if three irrigations are performed, modifier 52 should be used to indicate it was a reduced service.

Our second code is 92537.

If you’re wondering about the code descriptions for 92270 and 92538, they are:

  • 92270, electro-oculography with interpretation and report. This code is used for reporting saccadic eye movement testing with recording.
  • 92538, caloric vestibular test with recording, bilateral; monothermal (ie, one irrigation in each ear for a total of two irrigations.

If you found this helpful, be sure and check out some of my other coding exercises, including: