Vestibular Reimbursement – Part IV

Development of a CPT Code

As I have stated previously, “Technology moves faster than policy. On many occasions there are well accepted, clinically proven advancements in procedures that render the original coding language obsolete. When faced with this situation, the clinician must decide to: 1. Continue to perform the procedure as described despite having access to “a better way,” 2. Run the risk of performing and billing for a procedure that may not fit the coding language, which can result in penalties and/or requests for repayment, or 3. Petition the American Medical Association (AMA) to develop a new code or update the language of the code to address technological advances. The third option is a long and involved process.

When a company develops a new product, such as Active Head Rotation (VAT and Vorteq), or current equipment can be used for a new application, such as using ABR equipment for VEMPs, it has the option of seeking a CPT code for that procedure. There is a bit of a Catch 22 in developing a new code because the AMA won’t issue a code unless there is widespread usage, and it is hard to achieve widespread usage when there is no code or reimbursement associated with that procedure.

In order to obtain data regarding widespread use, an application can be made for a Category III code. This involves describing the service, and assigning a five-digit identification code. Even though Medicare and most other insurance won’t reimburse for that code, data is gathered each time the code is submitted.

Once the code has been established as widely used and effective (based on peer-reviewed literature), an application can be made for a Category I code. A Category I code can proceed through the American Medical Association (AMA) RUC process for valuation and recommendation to Medicare for reimbursement.

About Alan Desmond

Dr. Alan Desmond is the director of the Balance Disorders Program at Wake Forest Baptist Health Center, and holds an adjunct assistant professor faculty position at the Wake Forest School of Medicine. In 2015, he received the Presidents Award from the American Academy of Audiology.