Billing & Coding for Pediatric Audiology Services

What is an ICD code?

The International Classification of Diseases (ICD) codes are numeric or alpha-numeric codes that are used to classify a diagnosis. The ICD-CM (Clinical Modification) is the version of ICD that is used in the United States.

The U.S. transitioned from ICD-9-CM (9th Revision) in October 2015 and is currently using the ICD-10-CM (10th Revision).

What ICD code do you report when results are normal?

Coding for diagnostic tests should be consistent with the following guidelines:

• Code for the result of the diagnostic test.
• In the case of a normal result, the next choice would be to choose a diagnosis code that reflects the reason for the referral and/or the chief presenting complaint.
• It is helpful to include other secondary diagnosis codes that will help paint a clear clinical picture of why the test(s) are being performed.

What ICD code should I report when newborn hearing screening follow-up tests are normal?

There is significant variability in payer policies regarding reporting a normal examination following a failed newborn hearing screening. Please confirm with your payer regarding diagnosis coding requirements for newborn hearing re-screening.

What is a CPT code?

Current Procedural Terminology (CPT®) codes (developed and maintained by the American Medical Association) are five-digit codes that designate a distinct test or therapeutic procedure. Each code has a description of the procedure or group of procedures that are included with the code. The procedure(s) included in the description are used to assess the value of that code.

What are some general principles of correct coding and billing for pediatric testing?

• Choose the CPT code that best represents the procedure that was performed. In other words, what type of testing technique was used to obtain your clinical findings?
• Most audiology CPT codes (with the exception of VRA) are valued based on the procedure being performed on both ears. If you are performing the testing on one ear, it may be appropriate to use a reduced service modifier (-52) to indicate that the entire procedure was not completed.
• General coding instructions indicate that, at times, it may be appropriate to append modifiers to services billed on a claim.
• The -52 modifier can be used for reduced services (e.g. unilateral testing as opposed to bilateral testing).
• The -22 modifier can be used when significantly extended services are provided that may require additional equipment (e.g. Auditory Steady State Response in addition to Auditory Brainstem Response testing).
• Be aware that some payers, including many state Medicaid programs, do not acknowledge all modifiers. In these cases, including a modifier with a code may delay the correct processing of the claim. If you utilize modifiers frequently for a particular service, it is best to check the payment policies of the payer.
• Documentation in the patient’s medical record should support the reason that testing was completed and the reason why particular codes are being billed. Payers may deny payment if documentation is missing or is not consistent with the codes billed.