星空入口

Question: In a recent note on a patient who came in for vestibular testing following an episode of vertigo, the provider wrote, 鈥淐alorics: Abnormal (cool only 37% right stronger, total of 35deg/sec).鈥� But the provider also wrote, 鈥淧atient unable to complete bithermal caloric testing. Results of cool irrigations reveal probable left ear unilateral weakness.鈥�

Is this enough to support 92537? I only see cool solution, not warm. Also, it looks like only one ear was irrigated. Does this mean I would append modifier 52 per CPT^脪 guidelines?

星空入口Forum Participant

Answer: For this encounter, you do not have enough information to support 92537 (Caloric vestibular test with recording, bilateral; bithermal (ie, one warm and one cool irrigation in each ear for a total of four irrigations)) for two reasons.

First, the provider only performed two irrigations, not four, which is required to report 92537. Second, 92537鈥檚 descriptor notes the irrigations for that service should irrigate with both warm and cold water in each ear. Your provider, as you said, only used cold water.

However, the service your otolaryngologist provided does support 92538 (Caloric vestibular test with recording, bilateral; monothermal (ie, one irrigation in each ear for a total of two irrigations)). The note describes one irrigation per ear, for a total of two irrigations. Even though the patient was unable to complete the left ear irrigation per the note, the irrigation that your provider performed did produce a result of 鈥減robable left ear unilateral weakness.鈥� The provider also used only one water temperature 鈥� cold 鈥� making the test monothermal.

This would be enough to justify billing 92538 and, as your otolaryngologist provided the full 92538 service, you would not append modifier 52 (Reduced services).

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC