As cochlear implant awareness increases and more individuals receive cochlear implants, the demand for related audiological services is growing across the country. To meet this need, many audiologists have begun to add, or are considering adding, cochlear implant services to their practices.
Audiologists who are not familiar with the details of how to correctly bill for cochlear-implant services may inadvertently negatively impact their clinic's reimbursement outcome. By avoiding the following common pitfalls, audiologists may be able to improve their clinic's reimbursement for cochlear-implant services.
Pitfall 1: Use of Codes Not Allowed by the National Correct Coding Initiative
The National Correct Coding Initiative (CCI) has designated codes that cannot be billed in conjunction with 92601, 92602, 92603, and 92604 (see Table 1). Allowable CPT codes should be billed by attaching modifier 59 to each allowable code (allowable codes are shown in Table 1, Column 2). The modifier 59 communicates to the payer that the procedure is separate and distinct from the cochlear-implant programming code. It should be noted that Medicare and Medicaid programs use these guidelines, but not all payers will follow them. Audiologists should contact payers to confirm payer-specific guidelines.
Pitfall 2: Inappropriate Use of 92626 and/or 92627
Inappropriate use would include using these codes to bill for time spent counseling cochlear-implant candidates and recipients and troubleshooting cochlear-implant equipment. Rather, these codes should be used when evaluating auditory function to determine the need for auditory rehabilitation, such as cochlear implantation, or when evaluating auditory function for the purpose of monitoring progress after intervention. For example, time spent assessing residual hearing, aided-detection thresholds, and aided-speech-perception abilities (e.g., administering the AzBio sentence test) can be billed for using these codes.
It is important to be aware of the following when using these codes:
- 92626 and 92627 are both time-based codes and can only be billed when the procedure takes at least 51 percent of the designated time for the code used. For example, if the procedure takes 30 minutes or less, 92626 cannot be billed, as the code description specifies this code is for the first hour of evaluation.
- If the procedure takes more than 60 minutes, 92627 can be used to bill for each additional 15-minute increment beyond the first 60 minutes. This code cannot be used to bill for 15-minute increments in isolation.
- Modifier 52, which indicates to the payer that the procedure was reduced, cannot be used in conjunction with time-based codes to bill for procedures taking less than 51 percent of the designated time.
- If cochlear-implant programming (92601–92604) is completed on the same day as these codes, modifier 59 must be attached to each unit of 92626 and 92627.
- The time used to complete the procedure must be documented in chart notes when time-based codes are used.
Pitfall 3: Not Billing for Programming of Bilateral Cochlear Implants
Audiologists can, and should, bill for bilateral programming of cochlear implants. CPT codes 92601–92604 billed in isolation reflect unilateral cochlear-implant programming, but modifiers can be used to indicate bilateral programming. Audiologists should consult with payers to determine payer-specific guidelines for billing bilateral programming, as there are multiple ways in which modifiers can be used to indicate that bilateral cochlear implant programming was completed.
The following examples demonstrate possible ways in which bilateral cochlear-implant programming might be billed for a returning adult cochlear-implant recipient:
Example 1: Use of modifier 76 to indicate a repeat procedure
Example 2: Use of LT and RT modifiers
Example 3: Use of modifier 50 to indicate a bilateral procedure
Example 4: Use of modifier 22 to indicate increased procedural service
|CPT PROCEDURE CODE (ONE)||CPT PROCEDURE CODE (ONE)||CAN BE PERFORMED ON THE SAME DAY OF SERVICE IN AN OFFICE SETTING?||CAN BE PERFORMED ON THE SAME DAY OF SERVICE IN HOSPITAL OUTPATIENT SETTINGS?||IF CAN BE PERFORMED ON THE SAME DAY OF SERVICE, WHAT MODIFIER SHOULD BE USED?|
|92601||92507, 92508, 92521-92524, 92550, 92567, 92568, 92570, 92585, 92586, 92604, 92626||Yes||Yes||-59|
|92601||92552-92565, 92571-92584, 92587-92588, 92596-92597, 92602, 96532,97755||No||No|
|92602||92507, 92508, 92521-92524, 92550, 92567, 92568, 92570, 92585, 92586, 92626||Yes||Yes||-59|
|92602||92552-92565, 92571-92584, 92587-92588, 92596-92597, 92604, 96532, 97755||No||No|
|92603||92507, 92508, 92521-92524, 92550, 92567, 92568, 92570, 92585, 92586, 92602, 92626||Yes||Yes||-59|
|92603||92552-92565, 92571-92584, 92587-92597, 92603, 92604, 96523||No||No|
|92604||92507, 92508, 92521-92524, 92550, 92567, 92568, 92570, 92585, 92586, 92626||Yes||Yes||-59|
|92604||92552-92565, 92571-92584, 92587-92597, 96523, 97755||No||No|
To accurately reflect our diagnosis and procedures performed for cochlear implant services, it is important that audiologists both correctly code for the services provided and avoid the pitfalls outlined earlier. When a portion of a claim is coded incorrectly, the entire claim could be denied.
Due to the lack of uniformity among payers in coding for certain services—for example, bilateral programming—it is important that clinics closely monitor the received reimbursement so that appropriate modifications can be made to maximize reimbursement. Clinics may also consider using coding and reimbursement services provided by cochlear implant manufacturers to identify opportunities to refine billing and reimbursement practices.
In summary, audiologists providing cochlear-implant services can work toward optimizing reimbursement for cochlear-implant services by correctly coding the services provided, closely monitoring reimbursement trends, and seeking the assistance of cochlear implant manufacturers to reduce the amount of time spent providing non-billable services and to assist in identifying opportunities to maximize reimbursement.
*CPT codes, descriptions, and other data are copyright 1966, 1970, 1973, 1977, 1981, 1983–2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.