In July 2019, the American Academy of Audiology released its Clinical Practice Guidelines for Cochlear Implants (CIs) (Messersmith et al, 2019). Cochlear implantation is a surgical procedure for the treatment of severe to profound sensorineural hearing loss in both children and adults. 

In the United States, approximately 76.8 individuals out of every 10,000 with severe to profound hearing loss pursue a new CI each year (Healthy People 2020 Midcourse Review, 2016). This article focuses on guidance for filing claims for services provided to patients before and after cochlear implantation.

Candidacy Evaluation

The Academy’s new clinical practice guidelines recommend audiometric and aided threshold testing and speech-perception testing using appropriately fit amplification, as well as non-behavioral tests of auditory system function (e.g., otoacoustic emissions, immittance testing, and auditory brainstem response) (Messersmith et al, 2019). Additionally, counseling should be completed during the candidacy evaluation. 

Coding for threshold testing and non-behavioral tests of auditory-system function are beyond the scope of this article. 

Time spent completing aided-speech-perception testing and preoperative counseling can be billed as evaluation of auditory function, as described below.

  • 92626 Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status of a surgically implanted device(s): first hour
  • 92627 Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status of a surgically implanted device(s): each additional 15 minutes

Codes 92626 and 92627 include assessment of auditory function to determine a patient’s candidacy for and progress with surgically implanted devices, proficiency in speech understanding with their hearing loss, as well as face-to-face time spent with the patient or family. Codes 92626 and 92627 also include the use of inventories and speech-discrimination testing to determine the patient's functional hearing capabilities.

These are time-based codes; 92626 should be used when the procedure lasts at least 31 minutes. Use of the -52 Reduced Services modifier is not recommended for use with 92626 if evaluations last for less than 31 minutes. For assessment lasting longer than 60 minutes, 92627 is used for each additional 15-minute increment thereafter. It is inappropriate to bill 92627 in isolation without the use of 92626. Providers should include documentation of start and stop times in patients’ medical records.

New definitions of 92626 and 92627, effective January 1, 2020, do not include hearing aid evaluation, selection, fitting, and follow-up codes (92590–92595); it is now designated specifically for use with surgically implanted devices. Further, 2020 updates to the Centers for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (NCCI) indicate that 92590–92591 (hearing aid examination and selection), 92592–92593 (hearing aid check), and 92594–92595 (electroacoustic evaluation for hearing aid) are not payable when billed on the same date of service as 92626 or 92627 (CMS, 2020).

Surgical Intraoperative Measures 

The Academy’s clinical practice guidelines recommend intraoperative test measures by the audiologist, which may include evoked stapedial reflex thresholds (ESRT), electrically evoked compound action potentials (ECAP), neural response telemetry (NRT), neural response imaging (NRI), and auditory nerve response telemetry (ART) in order to verify the function of the device during surgery (Messersmith et al, 2019). The following represent coding options that could be used:

ESRT measurements:

  • 92568 Acoustic reflex testing, threshold, or
  • 92550 Tympanometry and reflex threshold measurements

ECAP, NRT, NRI, or ART measurements:

  • 92584 Electrocochleography

Use of 92584 for ECAP measurements is recommended based on guidance in the July 2011 CPT Assistant (American Medical Association). We recommend that practitioners check directly with payers if using codes other than CPT code 92584 for ECAP measurements and CPT codes 92568 or 92700 for ESRT measurement. 

Of note, the NCCI specifies that CPT code 92584 may not be billed on the same date of service as the cochlear implant programming CPT codes 92601–92604. However, CPT codes 92568 and 92550 can be billed on the same date of service as 92601–92604 using the -59 Distinct Procedural Service modifier. This issue is addressed in the Device Programming section to follow and has been discussed in detail by a previous issue of Audiology Today (Brown, 2019).

Device Programming

The Academy’s clinical practice guidelines recommend measuring electrode impedances, establishing the electrical dynamic range (EDR) via behavioral and objective measures, including ESRT and ECAP measures; optimizing the programming via loudness balancing and pitch scaling; and ensuring comfort and reliability (Messersmith et al, 2019).

The minimum codes for device programming are designated by patient age and initial or subsequent programming session. Procedures involved in measuring impedances, establishing the EDR, and optimizing the programming would all be included in the codes below for device programming. These codes do not include services pertaining to evaluation of auditory function (92626, 92627) after cochlear implantation.

Initial Stimulation:

  • Adult interacting with young child with cochlear implant92601 Diagnostic analysis of CI, patient younger than 7 years of age, initial programming
  • 92603 Diagnostic analysis of CI, age 7 years or older, initial programming

Subsequent Reprogramming:

  • 92602 Diagnostic analysis of CI, patient younger than 7 years of age, subsequent reprogramming
  • 92604 Diagnostic analysis of CI, age 7 years or older, subsequent reprogramming

These codes billed in isolation reflect unilateral cochlear implant programming. Billing for bilateral cochlear implant programming may be billed differently for some payers with the use of modifiers. It is recommended you consult with your payer regarding coding for unilateral versus bilateral programming to determine if they allow coding in this manner, which modifiers will be accepted for reimbursement, and under what circumstances they will be accepted. Examples of possible modifiers are shown below (Brown, 2019).

Example 1: Use of -76 modifier for a repeat procedure

  • 92604 (first device)
  • 92604-76 (repeat procedure on second device)

Example 2: Use of LT and RT modifiers 

  • 92604-LT
  • 92604-RT

Example 3: Use of -50 modifier to indicate a bilateral procedure 

  • 92604-50

Example 4: Use of -22 modifier to indicate an unusual procedural service 

  • 92604-22 

As objective measures, ESRT and ECAP measures are also used in the programming of the CI. If these procedures are completed as part of the cochlear implant programming session, the services are not considered separate and distinct. Thus, if ESRT and/or ECAP measurements are used for the purposes of programming the device, no procedure code should be billed in addition to the 92601–92604 code.

Device Validation

The Academy’s clinical practice guidelines recommend outcomes assessments at regular intervals after initial stimulation to document device benefit, as well as to determine if any programming adjustments are necessary (Messersmith et al, 2019). Such outcome measures may include the use of functional inventories, speech-perception assessment, and face-to-face subjective interaction with the patient and family, similar to measures performed preoperatively at the candidacy assessment. 

As mentioned earlier, time spent in obtaining outcome inventories, speech perception assessment, and face-to-face patient interaction can be billed using the codes below.

  • 92626 Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status of a surgically implanted device(s): first hour
  • 92627 Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status of a surgically implanted device(s): each additional 15 minutes

Device Parts and Supplies

Numerous supplies may be billed in association with a patient’s device(s). A list of these codes can be found on the Academy’s website (audiology.org; go to Practice Management > Coding > ICD-10). Many clinics have found that it is not cost-effective to directly bill for cochlear implant equipment. Readers are reminded that direct billing is also available through CI manufacturers for many payers.

Conclusion

Adults and children with severe to profound hearing loss can benefit greatly from cochlear implantation and reap the quality of life benefits associated with better hearing. While clinics specializing in this area are few, the addition of CI to your practice provides an opportunity to help more patients by mitigating the deleterious effects of more severe hearing losses. 


*CPT codes, descriptions, and other data are copyright 1966, 1970, 1973, 1977, 1981, 1983–2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

DISCLAIMER

The information provided in this article by the American Academy of Audiology Coding and Reimbursement Committee is to provide general information and educational guidance to audiologists. Action taken with respect to the information provided is an individual choice. The American Academy of Audiology hereby disclaims any responsibility for the consequences of any action(s) taken by any individual(s) as a result of using the information provided, and the reader agrees not to take action against, or seek to hold, or hold liable, the American Academy of Audiology for the reader's use of the information provided. As used herein, the "American Academy of Audiology" shall be defined to include the Academy's directors, officers, employees, volunteers, members, and agents.