Clinical Decisions – Yes or No
Last week, we discussed how vestibular function test codes are broken down into technical (TC) and professional (PC) components. Not all audiology codes are broken down this way. For example, basic comprehensive audiometry (CPT Code 92557) does not have TC/PC components. A code that does not have a TC component must be furnished directly by a physician, qualified audiologist, nurse practitioner or clinical nurse specialist, but not by a technician. A TC code can be performed by a non-professional technician under the supervision of a physician.
If you recall, there was a lot of publicity a few years back regarding the basic comprehensive audiometry code. Historically, physicians who employed technicians or audiologists were billing for this code as if they had performed the audiogram themselves.* Medicare had no way of knowing who did the test, or what qualifications they had. Medicare made it clear that if an audiogram is performed by an audiologist, it must be billed under that audiologist’s identification (NPI) number.
*I am not implying any sinister intent with this billing practice. In many cases, it was simply a matter of convenience for the employer physician to bill all services performed in his/her office through their own billing identification number. Particularly with a new hire, it can take months to get an identification number assigned to an employee audiologist.
So, some tests can be billed if performed by a technician, others cannot. This is where I get confused. I have no idea how, when, why or who decided that vestibular function tests can be performed by a technician, but an audiogram cannot. Are we to infer that an audiogram is more difficult to perform than a caloric irrigation, or a Dix-Hallpike test? It would seem that someone making these decisions thinks so.
Let’s go back to a statement from last week’s blog, “Medicare rules mandate that “A technician may not perform any part of a service that requires clinical decision making. For example, a technician may not interpret test results or engage in clinical decision making” (CMS transmittal 1975, 2010). Anyone who performs the Dix-Hallpike test knows that there is quite a bit of clinical decision making going on. The VNG only records horizontal and vertical eye movement, while the most common nystagmus response is rotary and does not record well. It must be visually observed. Of course, if the interpreting physician is viewing video after the fact, as opposed to tracing of eye movements, accurate diagnosis can be made. Then again, there is never a better time to perform Canalith Repositioning than immediately after a positive Dix-Hallpike, so best patient care calls for a clinical decision maker to be in the room, performing the exam.
Next week, a look at how a code is developed.