LCD/NCD Portal

L29305 VESTIBULAR FUNCTION TESTS

 

 

06/14/2011

 

 

Indications and Limitations of Coverage and/or Medical Necessity

 

• This Local Coverage Determination (LCD) will define the vestibular function tests and the criteria for coverage for procedure codes 92541 through 92547 only.

• This LCD does NOT address Computerized Dynamic Posturography (CDP) or audiometry tests.

o Please refer to those individual LCDs for coverage criteria.

Indications for vestibular function testing:

• A complete picture of the patient is necessary to determine if diagnostic testing is warranted.

o A complete history, physical exam and review of medications must be performed before ordering diagnostic tests.

• By performing the history and physical and medication review, the physician can often differentiate between vestibular and non-vestibular dizziness.

o The differentiation of the two is important because true spinning vertigo is often inner ear related and non-vertigo symptoms may be due to inner ear problems as well as CNS, cardiovascular, or systemic diseases or by medications that cause cardiovascular, CNS or ototoxic symptoms.

o In the case where it is clearly evident that the symptoms are non-vestibular in nature, then vestibular testing should not be done.

o However, if the physician cannot definitively differentiate between the two and feels vestibular testing is justified, then the medical record should clearly support the need to proceed with vestibular testing.

• Evaluating the VOR requires application of a vestibular stimulus and measurement of the resulting eye movements.

o Quantitative test of physiological processes under vestibular control can be useful in identifying the cause of the patient’s symptoms, confirming findings noted on the history and physical exam, planning therapeutic interventions and monitoring the response to those interventions.

• A standard vestibular function test battery includes

o tests of visual ocular control

o a careful search for pathologic nystagmus with fixation and

o with eyes open in darkness and

o With measurement of induced physiologic nystagmus.

• The following vestibular function tests are covered under this LCD:

o 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

o 92541—Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording.

 ENG electrodes or video goggles are placed and the patient is asked to look straight ahead, 30-45 degrees to the right and 30-45 degrees to the left.

 Recordings are made to detect spontaneous nystagmus.

o 92542—Positional nystagmus test, minimum four positions, with recording

 The patient is placed in a variety of positions, including supine with head extended dorsally, left and right and sitting, in an attempt to induce nystagmus.

 With the patients eyes closed, an ENG recording is made or with the patients eyes wide open in total darkness a VNG recording is made to detect nystagmus.

o 92543—Caloric vestibular test, each irrigation (binanural, bithermal stimulation constitutes four tests), with recording.

 Each ear is separately irrigated with cold water/air and then warm water/air to create nystagmus in the patient.

 ENG/VNG recordings are evaluated to detect any difference between the nystagmus of the right side and the left side.

 Four irrigations occur, warm and cold irrigations for both the right and left ears.

o 92544—Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording

 This test is usually performed with moving LED lights, with the patient watching the movement of the lights to the right and left.

 ENG electrodes or VNG recordings are used to record nystagmus.

o 92545—Oscillating tracking test, with recording

 With ENG electrodes or video goggles in place, the patient watches an LED light moving in a pendular motion.

 A recording is made of the eye tracking motion.

 The recording is then analyzed for smoothness.

o 92546—Sinusoidal vertical axis rotational testing

 The patient is seated in a rotary chair with the head bent forward 30 degrees.

• ENG electrodes are placed or VNG goggles are placed to measure nystagmus while the chair is rotated with the patients eyes closed.

• A recording is made and studies to determine and abnormal labyrinthine response on one side or the other.

• Auto Head Rotation Tests, sometimes referred to as Active-Head Rotation Tests, involves recording head and eye position while the patient actively turns his or her head side to side or up and down at progressively faster frequency, may be performed if the rotary chair is not available/used.

• These tests are not “head-shake” tests.

o 92547—Use of vertical electrodes (list separately in addition to code for primary procedure)

 ENG electrodes are placed to measure vertical and rotary nystagmus.

• For the purpose of this LCD, both VNG and ENG are acceptable methods used to record findings from the above-mentioned tests.

• All diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary’s specific medical problem.

o Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary (42 CFR § 410.32).

o All diagnostic tests covered under section 1861 (s)(3) of the Act and payable under the physician fee schedule must be furnished under the appropriate level of supervision by a physician as defined in section 1861 (r) of the Act.

o Services provided without the appropriate level of supervision are not reasonable and necessary.

• The diagnostic tests covered in this LCD require a general level of supervision.

o General supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure.

o Under general supervision, the training of the non-physician personnel that actually performs the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.

o Diagnostic tests personally furnished by a qualified audiologist as defined in section 1861 (II)(3) of the act are not subject to the general supervision policy described above (42 CFR § 410.32).

• Diagnostic testing, including hearing and balance assessment services, performed by a qualified audiologist is covered as “other diagnostic tests” under §1861 (s) (3) of the Act when a physician orders such testing for the purpose of obtaining information necessary for the physician’s diagnostic evaluation or to determine the appropriate medical or surgical treatment of a hearing deficit or related medical problem.

o Services are excluded by virtue of §1862 (a)(7) of the Act when diagnostic information required to determine the appropriate medical or surgical treatment is already known to the physician, or the diagnostic services are performed only to determine the need for or the appropriate type of hearing aid.

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

• See Pub. 100-02, Chapter 15, Section 80.3 for a complete discussion on audiological diagnostic testing requirements, including ordering, performing coverage and payment

• Vestibular Function Tests may be covered when performed by a qualified audiologist or the physician treating the patient.

For the diagnostic tests in this LCD, the physician should have training and expertise as defined below:

Training and Expertise

• CMS Online Manual System, Pub. 100-08, Program Integrity Manual, Chapter 13, Section 5.1 outlines that “ reasonable and necessary” services are “ordered and/or furnished by qualified personnel.”

o A qualified physician for this service/procedure is defined as follows:

 A) Physician is properly enrolled in Medicare.

 B) Training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty in the United States or must reflect equivalent education, training, and expertise endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States.

• Services will be considered medically reasonable and necessary only if performed by appropriately trained providers.

o This training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in

 Otolaryngology,

 Neurology or

 Otology/Neurology or

 must reflect extensive continued medical education activities.

• Section 1861(11)(3) of the Act, provides that 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:

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

o In the case of an individual who furnishes services in a State which does not license audiologist

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

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

o  Successfully completed a national examination in audiology approved by the Secretary.

• For Audiologist in the State of Florida, the requirements for licensure in the areas of education, supervised clinical requirements and professional experience requirements were revised effective July 25, 2006.

o These requirements can be found in The 2006 Florida Statutes, Chapter 468, Part I, ss 468.1105-468.1315. For this LCD, an audiologist must meet all the requirements outlined in the Statutes.

Limitations:

• If a beneficiary undergoes diagnostic tests performed by an audiologist without a physician referral, the tests are not covered, even if the audiologist discovers a pathological condition.

• Diagnostic tests ordered before a physician performs a complete history, physical and medication review to rule out non-vestibular causes of balance problems, will not be seen as medically reasonable and necessary.

• When diagnostic information required to determine the appropriate medical or surgical treatment is already known to the physician, or the diagnostic services are performed only to determine the need for or the appropriate type of hearing aid, these services are not covered.

 

 

CPT/HCPCS Codes

 

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

92541 SPONTANEOUS NYSTAGMUS TEST, INCLUDING GAZE AND FIXATION NYSTAGMUS, WITH RECORDING

92542 POSITIONAL NYSTAGMUS TEST, MINIMUM OF 4 POSITIONS, WITH RECORDING

92543 CALORIC VESTIBULAR TEST, EACH IRRIGATION (BINAURAL, BITHERMAL STIMULATION CONSTITUTES 4 TESTS), WITH RECORDING

92544 OPTOKINETIC NYSTAGMUS TEST, BIDIRECTIONAL, FOVEAL OR PERIPHERAL STIMULATION, WITH RECORDING

92545 OSCILLATING TRACKING TEST, WITH RECORDING

92546 SINUSOIDAL VERTICAL AXIS ROTATIONAL TESTING

92547 USE OF VERTICAL ELECTRODES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

 

 

ICD-9 Codes that Support Medical Necessity

 

386.00 MÉNIÈRE'S DISEASE, UNSPECIFIED

386.01 ACTIVE MÉNIÈRE'S DISEASE, COCHLEOVESTIBULAR

386.02 ACTIVE MÉNIÈRE'S DISEASE, COCHLEAR

386.03 ACTIVE MÉNIÈRE'S DISEASE, VESTIBULAR

386.04 INACTIVE MÉNIÈRE'S DISEASE

386.10 PERIPHERAL VERTIGO UNSPECIFIED

386.11 BENIGN PAROXYSMAL POSITIONAL VERTIGO

386.12 VESTIBULAR NEURONITIS

386.19 OTHER PERIPHERAL VERTIGO

386.2 VERTIGO OF CENTRAL ORIGIN

386.30 LABYRINTHITIS UNSPECIFIED

386.31 SEROUS LABYRINTHITIS

386.32 CIRCUMSCRIBED LABYRINTHITIS

386.33 SUPPURATIVE LABYRINTHITIS

386.34 TOXIC LABYRINTHITIS

386.35 VIRAL LABYRINTHITIS

386.40 LABYRINTHINE FISTULA UNSPECIFIED

386.41 ROUND WINDOW FISTULA

386.42 OVAL WINDOW FISTULA

386.43 SEMICIRCULAR CANAL FISTULA

386.48 LABYRINTHINE FISTULA OF COMBINED SITES

386.50 LABYRINTHINE DYSFUNCTION UNSPECIFIED

386.51 HYPERACTIVE LABYRINTH UNILATERAL

386.52 HYPERACTIVE LABYRINTH BILATERAL

386.53 HYPOACTIVE LABYRINTH UNILATERAL

386.54 HYPOACTIVE LABYRINTH BILATERAL

386.55 LOSS OF LABYRINTHINE REACTIVITY UNILATERAL

386.56 LOSS OF LABYRINTHINE REACTIVITY BILATERAL

386.58 OTHER FORMS AND COMBINATIONS OF LABYRINTHINE DYSFUNCTION

386.8 OTHER DISORDERS OF LABYRINTH

386.9 UNSPECIFIED VERTIGINOUS SYNDROMES AND LABYRINTHINE DISORDERS

780.4 DIZZINESS AND GIDDINESS

 

 

Documentation Requirements

 

• The medical record must clearly indicate the medial necessity of the services being billed.

o In addition, documentation that the service was actually performed must be included in the patient’s medical record.

• The services covered in this LCD require a recording be obtained at the time the service is rendered.

o These recordings must be maintained in the patient’s medical record and be made available to Medicare upon request.

o The procedure report by itself is not enough to show that the services being billed are medically reasonable and necessary.

o Documentation of the medical necessity of the service is typically found in the office note when the service is performed in an office setting or the physician’s progress note(s) when the service is performed in a facility setting.

• The medical record must contain a detailed history and physical exam including a complete medication review.

o The medical record must support that other physiological/psychological, medication or other systemic reasons that could cause the balance problems were ruled out and that it is medically necessary to proceed with diagnostic testing of the vestibular system.

o The medical record must also contain the name and serial number of the equipment used to perform the vestibular tests.

• The physician ordering the vestibular test covered in this LCD must appear on the audiologist claim.

• All documentation requirements outlined above must be made available to Medicare upon request for review.

Utilization Guidelines

• It is rare that a specific symptom occurs in only one disease and that the diagnosis can be established based on the presence of this symptom only - a term called pathognomic.

o As many conditions have "overlapping" symptoms and findings, a methodical and thorough scientific approach must be used to narrow down the possibilities.

o The selection of diagnostic procedures is not random. It usually follows accepted clinical paradigms.

• The first step in any diagnostic evaluation is the history and physical examination.

o From here on, the provider develops a testing strategy depending on an individual patient's situation, her or his progression in the course of an illness, and the probability of an abnormal result for a given diagnostic test.

o Other considerations include the predictive values, invasiveness, and risks of certain testing modalities.

o This is not an all-inclusive list, and all aspects and pros and cons must be placed into perspective against the background of an individual patient's situation.

o For example, patients who have been previously diagnosed with coronary artery disease and who are stable generally do not need cardiac catheterization.

o However, once they develop unstable angina, they are subjected to coronary arteriography.

o Similarly, not all patients with headaches require a CT scan, but they do if there is reason to suspect an intracranial neoplasm or life-threatening vascular pathology.

• It is not appropriate to merely match a diagnostic test (CPT code) with a condition (ICD-9 code) for which it could be performed at some point and time during an episode of an illness.

o There must be a compelling patient care reason, and a constellation of factors that require the carrying out of this test must exist at the time when the testing is ordered and performed.

o Furthermore, the treating provider must be able to use the test results in the patient’s care.

o This rationale for ordering and performing a diagnostic test at a certain point in a patient's evaluation and treatment must be documented in the medical record.

• This prudent evaluative approach is not only a regulatory requirement (Code of Federal Regulations (CFR), Title 42, part 410.32).

o It is primarily the standard of accepted medical practice, as anchored in medical teaching and reputable peer reviewed medical literature.

o Diagnostic testing that is not in keeping with these principles is not reimbursable by Medicare.

• It is expected that these services would be performed as indicated by current peer reviewed medical literature and/or standards of practice.

o When services are performed in excess of established parameters, they are subject to medical review for medical necessity.

• It is generally not medically necessary to repeat the entire battery of vestibular function tests.

o In the instance where testing is performed to assess the efficacy of medical or surgical intervention, testing should be limited to those tests medically necessary to determine the success of treatment and guide further therapy.

o If the complete battery of tests is repeated, the medical record must clearly reflect the medical necessity of such an approach.

o When symptoms have resolved and then recurred absent any medical or surgical intervention, a repeat of the entire battery of tests must be substantiated by clear documentation in the medical record as to why extensive repeat testing is medically necessary.

• For procedure code 92543: if four tests are performed (i.e., warm and cold water each in the right and left ear) then 92543 is reported four times.

o If only one ear is irrigated or one temperature is used, then the corresponding number of codes should be reported (one irrigation= 92543x1; two irrigations= 92543x2, etc.).

o The maximum number of test reported is 4. The medical record should clearly support the number of tests that are reported.

• Medicare would not expect to see 92540, 92541, 92542 or 92544, 92545 or 92546 billed more than once during a session.

o If an additional unit of 92545 or 92546 were billed, it would be expected that the medical record documentation would clearly support the billing of an extra unit.

 

 

Treatment Logic

 

• The vestibular system is the system of balance and equilibrium.

• The vestibuloocular reflex (VOR) forms the basis for many of the clinical tests used to evaluate balance function. The vestibular system controls reflexes that maintain stable vision and posture.

• Vestibular function tests are tests of function.

o The tests are used to determine potential causes of balance disturbances, and they tests help to determine if there is a problem with the vestibular portion of the brainstem and inner ear.

o The balance system depends on the inner ear, the eyes and the muscles and joints to send information related to the body’s movement and orientation in space.

o When there are problems with the inner ear or other parts of the balance system, the patient may present with symptoms of vertigo, dizziness, imbalance or other symptoms.

 

 

Sources of Information and Basis for Decision

 

American Academy of Audiology (2004). Audiology: Scope of Practice. Retrieved 8/15/2006 from http://www.audiology.org.

 

American Academy of Audiology. Position Statement on the Audiologist’s role in the diagnosis & treatment of vestibular disorders. Retrieved 8/15/2006 from http://www.audiology.org.

 

American Medical Association, CPT Assistant, September 2006, Volume 16 issue 9; page13

 

Amin, M., et al (2005). Rotary chair testing. Retrieved 8/28/06 from http://www.emedicine.com/ent/topic480.htm.

 

Chawla, N. and Olshaker, J. (2006). Diagnosis and Management of Dizziness and Vertigo. Medical Clinics of North America, 90(2). W.B. Saunders Company.

 

Cummings, C. , Flint, P., et al (2005). Otolaryngology: Head & Neck Surgery, 4th ed. Part Twelve, Chapter 38. Mosby, Inc.

 

Fife, T.D., Tusa, R.J., et al (2000). Assessment: Vestibular testing techniques in adults and children. Report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology. American Academy of Neurology, 55, 1431-1441. Retrieved 8/28/06 from www.neurology.org.

 

Florida Statutes 2006. Available at www.leg.state.fl.us/statutes

 

Friedman, M. et al (2006). Dizziness, Vertigo and Imbalance. Retrieved 8/29/06 from http://www.emedicine.com.

 

Goldman, L., Arend, W., et al (2004). Cecil Textbook of Medicine, 22nd edition. 2439-2442, W.B. Saunders Company.

 

Hain, T. (2004). Vestibular Testing. Retrieved 8/28/06 from http://www.tchain.com/otoneurology/testing/engrot.html.

 

Shoup, A., et al (2005). Electronystagmography. Retrieved 8/29/06 from http://www.emedicine.com.

 

Vestibular Disorders Association (2005). Possible Symptoms of Vestibular Disorders. Retrieved 8/15/06 from http://www.vestibular.org.

 

06/14/2011

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

CMS LCD VESTIBULAR FUNCTION TESTS