Billing Edits for Auditory Processing Disorder In Effect April 1, 2012 As of April 1, 2012, audiologists may not bill certain codes together for the evaluation of (central) auditory processing disorder [(C)APD] for the same Medicare- or Medicaid-eligible patient on the same day. The restrictions are contained in the 2012 National Correct Coding Initiative (NCCI) edits. NCCI edits prohibit billing certain ... Bottom Line
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Bottom Line  |   April 01, 2012
Billing Edits for Auditory Processing Disorder In Effect April 1, 2012
Author Notes
  • Lisa Satterfield, MS, CCC-A, director of health care regulatory advocacy, can be reached at lsatterfield@asha.org.
    Lisa Satterfield, MS, CCC-A, director of health care regulatory advocacy, can be reached at lsatterfield@asha.org.×
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Hearing Disorders / Practice Management / Attention, Memory & Executive Functions / Bottom Line
Bottom Line   |   April 01, 2012
Billing Edits for Auditory Processing Disorder In Effect April 1, 2012
The ASHA Leader, April 2012, Vol. 17, 3. doi:10.1044/leader.BML.17052012.3
The ASHA Leader, April 2012, Vol. 17, 3. doi:10.1044/leader.BML.17052012.3
As of April 1, 2012, audiologists may not bill certain codes together for the evaluation of (central) auditory processing disorder [(C)APD] for the same Medicare- or Medicaid-eligible patient on the same day.
The restrictions are contained in the 2012 National Correct Coding Initiative (NCCI) edits. NCCI edits prohibit billing certain procedure codes on the same day and are intended to promote correct coding methods and to control improper coding leading to inappropriate payment. They are mandatory for Medicare and Medicaid services but optional for private health plans.
The Centers for Medicare and Medicaid Services (CMS) develops the NCCI edits based on definitions in the CPT (Current Procedural Terminology, © American Medical Association) manual, national and local policies, standard clinical practice, and current coding practices.
Evaluation and Individual Tests
Many audiologists administer and bill for (C)APD evaluations and individual tests because of an elaborate history surrounding the codes.
In 2005, CMS approved two new (C)APD evaluation codes. It took nearly two years of ASHA advocacy to receive approval for the codes: CPT 92620 (evaluation of central auditory function, with report; initial 60 minutes) and CPT 92621 (each additional 15 minutes). When the codes did receive approval, however, they were undervalued by CMS.
Clinicians responded to the low values by requesting that they be allowed to bill the individual test codes—specifically the filtered speech test (92571), staggered spondaic word test (92572), and synthetic sentence identification test (92576), in addition to the timed central auditory function codes. CMS, however, recommended that 92620 and 92621 not be billed in combination with 92571, 92572, or 92576. CMS indicated that the individual tests could be reported only if they are performed in isolation, using the single code representing that procedure. If a battery of tests is performed, the individual tests should not be billed in addition to 92620/92621.
CMS reasoned that using the time-valued codes (92620 and 92621) allows the audiologist to capture the time spent on the evaluation for site of lesion and other tests of central auditory function often used to determine the presence of (C)APD. Additionally, billing 92620 and 92621 avoids the suggestion that the three individual tests are required as part of the test battery to evaluate central auditory function, and instead allows the audiologist to determine the tests most appropriate for the patient.
Unanticipated Action
It was anticipated that NCCI would apply this soon after the CPT codes were published in 2005. The initial NCCI edit, however, did not prohibit billing the individual test codes with 92620 and 92621. Instead, it restricted billing 92506 (evaluation of speech, language, voice, communication, and/or auditory processing) with 92620 and 92621. This edit remains in effect.
Seven years later, NCCI is enforcing the edit that prohibits billing individual test codes with the timed codes. Therefore, as of April 1, billing 92620/92621 with 92571, 92572, or 92576 on the same day for Medicare or Medicaid patients is no longer allowed.
For updates and additional edits, visit ASHA’s reimbursement webpage.
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April 2012
Volume 17, Issue 5