My Head is Spinning: An Overview of Reimbursement and Balance Disorders The assessment of balance disorders and the provision of vestibular balance and rehabilitation therapy (VBRT) require many areas of knowledge and skills that are fundamental to both audiology and physical therapy. Accordingly, both professions have traditionally provided these services for adults and children with balance disorders. While this article discusses ... Bottom Line
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Bottom Line  |   December 01, 2001
My Head is Spinning: An Overview of Reimbursement and Balance Disorders
Author Notes
  • Maureen Thompson, is ASHA’s director of private health plans advocacy. Contact her by email at mthompson@asha.org.
    Maureen Thompson, is ASHA’s director of private health plans advocacy. Contact her by email at mthompson@asha.org.×
Article Information
Balance & Balance Disorders / Practice Management / Bottom Line
Bottom Line   |   December 01, 2001
My Head is Spinning: An Overview of Reimbursement and Balance Disorders
The ASHA Leader, December 2001, Vol. 6, 1-11. doi:10.1044/leader.BML.06232001.1
The ASHA Leader, December 2001, Vol. 6, 1-11. doi:10.1044/leader.BML.06232001.1
The assessment of balance disorders and the provision of vestibular balance and rehabilitation therapy (VBRT) require many areas of knowledge and skills that are fundamental to both audiology and physical therapy. Accordingly, both professions have traditionally provided these services for adults and children with balance disorders. While this article discusses scope of practice, it focuses primarily on billing and obtaining reimbursement—specifically, fitting these procedures into different payment puzzles, such as Medicare and private payers; selecting appropriate procedural and diagnostic codes; and using treatment efficacy data to enhance reimbursement.
Scope of Practice
Audiologists assess patients with balance disorders by evaluating the vestibular and extravestibular (visual and somatosensory) systems using a variety of procedures, which include, but are not limited to, electronystagmography (ENG), rotational tests, and posturography.
Audiologists also participate on the rehabilitation team for patients with balance system dysfunction. VBRT is a formulation of exercise activities customized to the needs of the patient, based on movements of the head and/or eyes or environmental visual movements.
Current Procedural Terminology (CPT) Codes
Listed below are the CPT codes used when requesting reimbursement for a balance system assessment and/or VBRT:
CPT 92541 spontaneous nystagmus test, including gaze and fixation nystagmus, with recording
CPT 92542 positional nystagmus test, minimum of four positions, with recording
CPT 92543 caloric vestibular test, each irrigation (binaural, bithermal, stimulation constitutes four tests), with recording
CPT 92544 optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording
CPT 92545 oscillating tracking test, with recording
CPT 92546 sinusoidal vertical axis rotational testing
CPT 92547 use of vertical electrodes in any or all of the above tests counts as one additional test
CPT 92548 computerized dynamic posturography
CPT 97112 neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, and proprioception
These services or procedures and their respective CPT code numbers are listed in a specific section (e.g., Special Otorhinolaryngologic Services) of the American Medical Association’s (AMA) CPT Manual. However, the use of codes is not restricted to a specific specialty group. The 2002 AMA CPT Manual states, “Any procedure or section of the CPT Manual may be used to designate the services rendered by any qualified physician or other qualified health care provider.”
An illustration of cross-specialty application of CPT codes is the use of CPT 97112 (i.e., neuromuscular reeducation of movement balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities) by an audiologist to bill for VBRT services. CPT 97112 is included under “Therapeutic Services” in the Physical Medicine and Rehabilitation section of the CPT Manual. Physical therapists are the professionals most often associated with the use of codes in the 97000 series. However, since VBRT is within the scope of practice of audiologists, they are not precluded from submitting a reimbursement claim with this procedure code.
ICD-9-CM Codes
A variety of ICD-9-CM (International Classification of Disease, 9th Edition, Clinical Modification) codes are available for use by audiologists in the 386 series (i.e., vertiginous syndromes and other disorders of vestibular system). In addition, 794.16 (i.e., abnormal vestibular function studies) is appropriate.
Medicare
Medicare, which is administered at the federal level by the Centers for Medicare and Medicaid Services (CMS), pays for diagnostic audiological tests when ordered by a physician to assist in the determination of the need for, or appropriate type of, medical and/or surgical treatment for a hearing loss or related medical condition. The physician referral for audiologic diagnostic tests must be noted in the clinical record. The referral should identify why the tests are needed, with as much detail as possible.
An audiologist may receive Medicare payments directly as an independent practitioner for a balance system assessment. However, only the technical component (see below) can be billed. For independently practicing audiologists, each Medicare carrier may dictate whether the physician referral is required in writing. Medicare does not reimburse independently practicing audiologists for therapeutic services (i.e., VBRT). Therefore, audiologists can only bill and receive payment directly from Medicare for VBRT if they are employed by the physician and bill “incident to physician’s services.”
In the Medicare Fee Schedule, there are two modifiers associated with vestibular function tests:
  • 26—which represents the professional component or the portion of the diagnostic test that involves a physician’s work.

  • TC—which represents the technical component or the portion of the diagnostic test, which does not include a physician’s participation (i.e., the audiologist’s work).

The “global value” for each code includes both the professional and technical components.
In the 2002 Medicare Fee Schedule, for example, the national global value for CPT 92541, spontaneous nystagmus, is $68.42; the technical component (i.e., audiologist’s work) is $45.97; and the professional component is $22.45. If an audiologist is an employee or contractor of the physician, then the full global value can be billed. On the other hand, if the audiologist is an independent practitioner, only the technical component can be billed.
Medicare rates will increase in 2002 above.
Private Payers
Private payers typically take their lead regarding reimbursement rates from Medicare and, as a result, may also increase reimbursement rates for vestibular function tests in the coming years. Please remember that, while Medicare will not reimburse audiologists for rehabilitation services, private health plans may have no such prohibition.
Treatment Efficacy
There is an impressive and growing body of literature that clearly demonstrates the efficacy of assessing and managing patients with balance disorders and/or dizziness. These data are a powerful tool for advocacy and negotiation. For example, Norre (1987) demonstrated that patients with benign paroxysmal positional vertigo who underwent a program of habituation exercises improved dramatically when compared with a sham exercise group and a non-treated control group. Horak and colleagues (1992) performed a controlled study comparing the benefits of a customized program of vestibular rehabilitation to two control groups. One group received medical therapy with meclizine or diazepam, and the other group performed a program of sham exercises. The vestibular rehabilitation group reported dramatic decreases in dizziness when compared with the two groups. Shepard and Telian (1995) compared the efficacy of a customized vestibular and balance rehabilitation program with a generic program of vestibular exercises. The customized therapy group showed statistically significant resolution of spontaneous nystagmus and rotational chair asymmetries at the end of therapy. Clinicians should use these and other data to negotiate reimbursement from third-party payers for balance system assessments and VBRT.
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December 2001
Volume 6, Issue 23