The vestibular evaluation can include a number of different procedures, and coding for these evaluations can often be confusing. There are several current procedural terminology (CPT®) codes that should be considered when completing your evaluation.

Basic Vestibular Evaluation

The American Medical Association (AMA) (2016) has identified several CPT codes that are considered “bundled.” A bundled code includes procedures that are most often billed together. Instead of billing all of the individual procedures, just the one bundled code would be reported. The basic vestibular evaluation (92540) is a bundled code, defined as including

  • 92541, Spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, 
  • 92542, Positional nystagmus test, minimum of four positions, with recording,
  • 92544, Optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording, and 
  • 92545, Oscillating tracking test, with recording.

These procedural components must be included in their entirety, including a minimum of four positional tests. If all four of these procedural components are not completed on a patient in a single encounter, it is inappropriate to use the bundled 92540 code. Instead, you report the individual codes for the procedures that were performed. However, since the intent of the basic vestibular evaluation is bundled to include four components, when filing the claim for this evaluation a modifier must be added to indicate the procedure was not completed as intended.

In such a situation in which all four of the procedures of the vestibular evaluation were not completed, a modifier 59 would be added to each of the individual codes that were performed to indicate that they were separate and distinct diagnostic procedures to indicate a distinct procedural service. When using the modifier 59, make sure there is appropriate documentation in the report as to why the full basic vestibular evaluation was not performed. Always remember, it is inappropriate to unbundle the vestibular evaluation code for the sole purpose of higher reimbursement by billing the components separately.

Dix-Hallpike

There is no specific CPT code for “Dix-Hallpike.” This maneuver is typically considered a positional component of 92542, positional nystagmus test, minimum of four positions. As noted earlier, CPT code 92542 is also included as part of the basic vestibular evaluation (92540). If performed in isolation, 92542 should be reported with the modifier 59 to indicate a distinct procedural service.

Caloric Irrigations

In 2016, in an effort to reduce coding confusion, CPT code 92543, caloric vestibular test, each, with recording, was deleted. Two codes were created in its place.

  • 92537, Caloric vestibular test with recording, bilateral; bithermal, (i.e., one warm and one cool irrigation in each ear for a total of four irrigations)
  • 92538, Caloric vestibular test with recording, bilateral; monothermal, (i.e., one irrigation in each ear for a total of two irrigations)

These CPT codes (92537 and 92538) cannot be reported together on the same date of service. In the event four irrigations were attempted but only three irrigations were actually performed, 92537 (bilateral, bithermal caloric vestibular test) should be reported with the modifier 52 to indicate a reduced procedural service. In the unlikely event that six irrigations were completed to include ice water calorics, 92537 should be reported with the modifier 22 to indicate an unusual procedural service, requiring significantly more time than usual.

Vestibular-Evoked Myogenic Potential (VEMP)

There is currently no specific CPT code for VEMP testing. In March 2017, the U.S. Food and Drug Administration (FDA) approved the Eclipse with VEMP system for the intended use of assessment of vestibular function (U.S. Food and Drug Administration, 2017). This is an important first step in demonstrating that VEMP testing is not an experimental/investigational procedure and beginning the process of developing a CPT code for VEMP. Since there is no CPT code available, the AMA, in the March 2011 issue of CPT Assistant, directed providers to use CPT code 92700, unlisted otorhinolaryngological service or procedure. Whenever billing an unlisted code such as 92700, it is important to consult your third-party payer guidelines for additional documentation requirements necessary for submission with the claim.

Rotary Chair

Rotary chair testing is typically billed with 92546, sinusoidal vertical axis rotational testing, billing one unit per plane of testing. This code should only be billed if your office has a room with a rotary chair. It is inappropriate to use this code for active head rotation tests such as VAT or VORTEQ, for headshake or spinning in an office-type chair. It is best to check with your third-party payer on billing multiple units. Additionally, some payers may require inclusion of the serial number of the rotary chair in your report documentation to demonstrate use of the rotary chair unit.

Computerized Dynamic Posturography

Dynamic posturography testing is typically billed with 92548, computerized dynamic posturography. Just as with rotary chair testing, this code should only be billed if your office has a room with a dynamic platform, though there is no standard set for this. It is inappropriate to use this code for measuring falls on foam. It is best to check with your third-party payer for whether or not they will reimburse for this procedure. Additionally, some payers may require inclusion of the serial number of the dynamic platform posturography system in your report documentation to demonstrate use of the dynamic platform.

The following cases illustrate some coding scenarios of these procedures in your vestibular assessment.

Case 1

You are completing a vestibular evaluation on a patient with a neck injury. Due to this injury, the patient cannot complete any positional tests. You complete the gaze, optokinetic, and oscillating tracking tests. You also are able to complete warm and cool irrigations in both ears. You would include the following codes with the modifier on your claim form:

  • 92541-59, Spontaneous nystagmus test, including gaze and fixation nystagmus
  • 92544-59, Optokinetic nystagmus test
  • 92545-59, Oscillating tracking test
  • 92537, Caloric vestibular, bilateral; bithermal

When using the modifier 59, make sure there is appropriate documentation in the report as to why the full basic vestibular evaluation was not performed. Always remember, it is inappropriate to unbundle the vestibular evaluation code for the sole purpose of higher reimbursement by billing the components separately.

Case 2

You are completing a vestibular evaluation on a patient with dizziness complaints. You complete the gaze, optokinetic, oscillating tracking tests, positionals head right and left, and Dix-Hallpike right and left. You complete warm caloric irrigations in both ears, which were completely normal, so cool irrigations were not performed. You also complete a cervical VEMP. You would include the following codes on your claim form:

  • 92540, Basic vestibular evaluation
  • 92538, Caloric vestibular, bilateral; monothermal
  • 92700, Unlisted otorhinolarynological procedure

Case 3

You are completing a battery of vestibular assessments on a patient with significant dizziness and balance complaints. You complete the gaze, optokinetic, oscillating tracking tests, positionals head and side right and left, and Dix-Hallpike right and left. You complete warm and cool irrigations in both ears. You also complete both cervical and ocular VEMP, computerized dynamic posturography, and rotational chair testing of the horizontal and vertical axes. You would include the following codes on your claim form:

  • 92540, Basic vestibular evaluation
  • 92537, Caloric vestibular, bilateral; bithermal
  • 92546, Sinusoidal vertical axis rotational testing, quantity of 2 
  • 92548, Computerized dynamic posturography
  • 92700, Unlisted otorhinolarynological procedure

Conclusion

This article is meant to provide an overview of billing and coding for vestibular evaluation. It is important to note, however, that insurance coverage, whether it is through Medicare or private payers, does not dictate clinical practice. In many cases, procedures like VEMPs, active head rotation, and saccade testing may be billed directly to the patient. For additional guidance on vestibular assessment, visit the Academy’s website, www.audiology.org/practice_management/coding/vestibular-testing.