L29299-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Tympanometry (L29299)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number

09102

Contractor Type

MAC - Part B

LCD Information

Document Information

LCD ID Number L29299

LCD Title Tympanometry

Contractor's Determination Number 92567

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/02/2009 Original Determination Ending Date

Revision Effective Date

Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See § 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: CMS Manual System, Pub. 100-04, Chapter 12, Section 30.3

CMS Manual System, Pub. 100-02, Chapter 15, Section 80.3

Transmittal 84, Change Request 5717, dated February 29, 2008

Transmittal 1470, Change Request 5717, dated February 29, 2008 Indications and Limitations of Coverage and/or Medical Necessity

Tympanometry is a test used to evaluate the condition of the middle ear system. The test determines the functionality of the tympanic membrane by observing its response to waves of pressure, and measuring the pressure of the middle ear. The test is used to measure parameters of the middle ear and eardrum in an effort to determine whether there are dysfunctions that could ultimately affect the hearing of the patient or put one at risk for repeated infections. Tympanometry is regarded as an objective technique for obtaining reproducible measurements of the compliance (also referred to as “admittance”) or mobility of the tympanic membrane and the pressure within the middle ear system. The measurements assist in assessing Eustachian tube function and in determining the continuity and mobility of the ossicular chain.

For Medicare coverage of audiologists performing hearing tests, the audiologists must be “qualified audiologists” as defined in the Medicare Benefit Policy Manual, Section 80.3.

A qualified audiologist is an individual with a master’s or doctoral degree in audiology. Therefore, a Doctor of Audiology (AuD) 4th year student with a provisional license from a State does not qualify unless he or she also holds a master's or doctoral degree in audiology. In addition, a qualified audiologist is an individual who:

• Is licensed as an audiologist by the State in which the individual furnishes such services; or

• In the case of an individual who furnishes services in a State which does not license audiologists, has

- Successfully completed 350 clock hours of supervised clinical practicum (or is in the process of accumulating such supervised clinical experience),

- Performed not less than 9 months of supervised full-time audiology services after obtaining a master’s degree or doctoral degree in audiology or a related field, and

- Successfully completed a national examination in audiology approved by the secretary.

Medicare will consider tympanometry reasonable and medically necessary when testing for the purpose of obtaining additional information necessary for his/her evaluation of the need for or appropriate type of medical or surgical treatment of a hearing deficit or other medical problem. The following are indications considered reasonable and medically necessary:

• To evaluate middle ear abnormalities suspected by clinical otoscopy

• To evaluate Eustachian tube patency

• To evaluate conductive hearing loss

• To evaluate perforations of the tympanic membrane

• To evaluate suspected fixation of the ossicular chain

• To evaluate middle ear function

• To evaluate lack of contact between conduction of the bones of the middle ear

• To document or follow persistent middle ear effusions

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. If a beneficiary undergoes diagnostic testing performed by an audiologist without a physician order, then these tests are not covered, even if the audiologist discovers a pathologic condition.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes

92567 TYMPANOMETRY (IMPEDANCE TESTING)

ICD-9 Codes that Support Medical Necessity

381.00 - 381.9 ACUTE NONSUPPURATIVE OTITIS MEDIA UNSPECIFIED - UNSPECIFIED EUSTACHIAN TUBE DISORDER

382.00 - 382.9 ACUTE SUPPURATIVE OTITIS MEDIA WITHOUT SPONTANEOUS RUPTURE OF EARDRUM - UNSPECIFIED OTITIS MEDIA

383.00 - 383.9 ACUTE MASTOIDITIS WITHOUT COMPLICATIONS - UNSPECIFIED MASTOIDITIS

384.00 - 384.9 ACUTE MYRINGITIS UNSPECIFIED - UNSPECIFIED DISORDER OF TYMPANIC MEMBRANE

386.11 BENIGN PAROXYSMAL POSITIONAL VERTIGO

386.12 VESTIBULAR NEURONITIS

386.19 OTHER PERIPHERAL VERTIGO

386.2 VERTIGO OF CENTRAL ORIGIN

386.30 - 386.35 LABYRINTHITIS UNSPECIFIED - VIRAL LABYRINTHITIS

387.0 - 387.9 OTOSCLEROSIS INVOLVING OVAL WINDOW NONOBLITERATIVE - OTOSCLEROSIS UNSPECIFIED

388.30 - 388.32 TINNITUS UNSPECIFIED - OBJECTIVE TINNITUS

389.00 - 389.08* CONDUCTIVE HEARING LOSS UNSPECIFIED - CONDUCTIVE HEARING LOSS OF COMBINED TYPES

389.10 - 389.18 SENSORINEURAL HEARING LOSS UNSPECIFIED - SENSORINEURAL HEARING LOSS, BILATERAL

389.20 - 389.22 MIXED HEARING LOSS, UNSPECIFIED - MIXED HEARING LOSS, BILATERAL

* Tests for the ICD-9 codes 389.00-389.08 are covered only for an initial evaluation of a hearing problem.

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation maintained by the performing physician must clearly indicate the medical necessity of the services being billed. In addition, documentation that the service was performed must be included in the patient’s medical record. The medical record should include the name and professional identity of the person who ordered and the person who performed the service. This information is normally found in the office/progress

notes, hospital notes, and/or procedure report.

Appendices

Utilization Guidelines N/A

Sources of Information and Basis for Decision

Audiology services-communication disorders-Auburn University. Tympanometry & acoustic reflex testing. Retrieved on May 1, 2002 from: http://frontpage.auburn.edu/communication_disorders/audiotempa.asp?file=tart.txt This source defines tympanometry and acoustic reflex testing from an audiology perspective.

Green, L.A., Culpepper, L. & DeMelker, R.A. (2000). Tympanometry interpretation by primary care physicians. [On-line]. Retrieved April 2, 2001 from: http://www.ahcpr.gov/research/jan01/101RA18.htm This source provides the definition of the procedure.

Howard, M.L. (2001). Middle ear, tympanic membrane, perforations from otolaryngology and facial plastic surgery/middle ear. [On-line]. Retrieved April 2, 2001 from: http://www.emedicine.com/ent/topic206.htm This source provides definitions and appropriate indications for the procedure.

Nussbaum, D. (2000). Understanding the audiological evaluation. [On-line]. Retrieved April 2, 2001 from: http://clerccenter.gallaudet.edu/SupportServices/series/5002.html This source provides definitions of the procedure and other audiology examinations as well as test implications and contraindications for use of tympanometry.

Petrek, M.R. (2000). Integrating physiologic technologies for hearing evaluation in infants and small children: an overview. Retrieved May 28, 2002 from: http://www.audiology online.com/audiology/newroot/articles/arc_disp.asp?catid=4&id=217 This source provides descriptions and indications of tympanometry from an audiology perspective.

Walsh, M. (2001). Otitis media from emergency medicine/ear, nose and throat. [On-line]. Retrieved April 2, 2001, from: http://www.emedicine.com/emerg/topic351.htm This source provided support for the contraindications of use of the procedure.

Advisory Committee Meeting Notes

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 12/04/2008

Revision History Number Original

Revision History Explanation Revision Number:Original Start Date of Comment Period:N/A

Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29299) replaces LCD L6698 as the policy in notice. This document (L29299) is effective on 02/02/2009.

Reason for Change